Washington County Human Services Department

Child Services Referral Form

333 E. Washington Street, Suite 2100, West Bend WI 53095 (262) 335-4583

Comprehensive Community Services

School Based Services

Coordinated Services Team

Strengthening Families

Lifespan Outpatient

Lifespan In-home

Adolescent IOP

Person making Referral / EXT
Role w/ client / Date of Referral
Name of Child

(First)(Middle)(Last)

Age / Date of Birth
T-19/ MA Number / Other Insurance

Reason for Referral

Parent(s) /Guardian(s) Name(s)

(First) (Middle)(Last)

(First)(Middle)(Last)

Child Lives With

((Name)(Relationship)

At

(Complete Address)

Current School

(School Name)(School Contact Person)

School Contact Information

(Address, Telephone, Contact Person email)

IEP (Yes or No)

Referring Party should discuss with the parent/guardian and child the program to which they will be referred and the purpose of the referral. Please identify the parent/guardian’s and child’s response to your discussion with them about the referral.

TELEPHONE NUMBERS

Home of Child / In Emergency
Mother / Work / Cell
Father / Work / Cell

Members of Household (List all persons living in the home with the child)

Full Name AgeRelationship to Child

List all other Family Members /Significant Others who are involved with the child or family

(Aunt, Uncle, Big Brother/Sister, Mentor, Grandparent)

Full Name AgeRelationship to Child

Current Mental Health Diagnosis(Include who made the diagnosis and the date)

List all current medications, dosage , & prescribing Physician:

List of Current and Past Services or Interventions provided to child(Hospitalizations, Crisis Services, Outpatient Services, Past and Present Court Orders, CPS reports, Past and Present Court Ordered Placements)

Intervention Name and ProviderDate(s)

Areas of Concern

Verbally assaultive (swearing at /threatening adults) / Argumentative / Disrespectful
Physically aggressive / has harmed or attempted to harm others / Threatens to harm peers/ others / Interpersonal problems-frequent verbal conflicts with peers /negative peer group
History of suicidal attempts / Threatens to harm self/ suicidal statements / Self harm gesturing (i.e. scratches self superficially)
Self mutilating behavior/ cutting / Mental Health diagnosis:
______/ Medical/ Developmental issues impacting mental health
Past History of psychiatric hospitalization/ alternative placement / Odd/unusual behaviors/ Bizarre vocalizations / Frequent mood swings (that are not developmentally typical)
Sexual acting out behavior / Enuresis/encopresis / Poor social skills (making friends, interacting)
Auditory/visual hallucinations / Risk behavior (Alcohol/ Drugs, gang, older peers)/ Criminal behavior / Low Self-esteem/Motivation
Lethargy
Delusional thinking / Paranoia / Victim of violence/witness to violence / Family issues
Damaged property in an angry/ emotional episode / Has experienced a loss (death/divorce/alienation) / Frequent Somatic Complaints
Recent loss of a parent / primary caregiver / Non-compliance with classroom/ school rules / Lack of self-responsibility/ accepting consequences
Blatant, intentional and persistent oppositional behavior in all settings / Hoarding/Stealing food / Anxiety /Perfectionism /Perseveration
Victim of abuse/ neglect; Exposure to significant traumatic experience / Other: / Other:

Family Background (Give brief history of the family, describe family dynamics, family roles and behaviors of the child)

Education/School Background (Give brief history of academic ability, attendance, special education classes, both positive and negative behaviors)

Community /Social Background (Give a brief history of how the child does in community and social settings or activities)

List the Strengths of the Child (Good with animals, creative, likes to read, can express needs, supportive family, etc.)

List the Strengths of the Family(Willing to learn new approaches, patient with child, organized, clean home)

What are the Goals /Outcomes you and the family anticipate achieving as a result of this referral?

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