Do Not Refer FFA Or Group Home Clients to ACT

Do not refer FFA or Group Home clients to ACT

19-Digit State Case Number: / J#: / Region/District:
Case Name: / Service Component: ER CDU FMA FMV FR PPA PPL
CSSW Name: / CSSW Telephone: / CSSW Cell Phone:
NEW REFERRAL
REFERRAL UPDATE (select one of the following choices): Additional Service Address Change Placement Change
Client Name: / Date of Birth: / SSN:
Caregiver Name (if applicable): / Caregiver Relationship: / Mother’s First Name:
If Client is a Child, Current Placement Type: Shelter Relative Foster Care Group Home Other:
Client/Caregiver Address: / Client’s Telephone:
Primary Language: / Disability: Yes No / Gender: Male Female / Marital Status:
Birth Place: / Highest Level of Education: / Ethnicity: / Hispanic
Non-Hispanic
Child’s First Removal Date: / Type of Transportation:
Personal Public / Asked Client if a Victim of Crime Report Was Filed?
Yes Claim Number: No
Client Currently Participating in Services? NO YES If yes, Type of Service: N/AIndividual TherapyPsychological TestingDomestic ViolenceConjoint/Family TherapyMedication EvaluationParentingGroup TherapyAnger ManagementIn-Home ServiceParent's UnitedSon's UnitedDaughter's United
Provider’s Name: / Agency:
Provider’s Address: / Provider’s Phone:
Service(s) Requested: FORTHWITH ORDER: YES (attach minute order) NO
Individual Therapy / Conjoint/Family Therapy / Group Therapy
Psychological Testing / Medication Evaluation / Anger Management
Domestic Violence / Parenting / In-Home Service
Parent’s United / Son’s United / Daughter’s United
ADDITIONAL CLIENT
Client Name: / Date of Birth: / SSN:
Caregiver Name (if applicable): / Caregiver Relationship: / Mother’s First Name:
Client/Caregiver Address: / Client’s Telephone:
Primary Language: / Disability: Yes No / Gender: Male Female / Marital Status:
Birth Place: / Highest Level of Education: / Ethnicity: / Hispanic
Non-Hispanic
Child’s First Removal Date: / Type of Transportation:
Personal Public / Asked Client if a Victim of Crime Report Was Filed?
Yes Claim Number: No
Client Currently Participating in Services? NO YES If yes, Type of Service: N/AIndividual TherapyPsychological TestingDomestic ViolenceConjoint/Family TherapyMedication EvaluationParentingGroup TherapyAnger ManagementIn-Home ServiceParent's UnitedSon's UnitedDaughter's United
Provider’s Name: / Agency:
Provider’s Address: / Provider’s Phone:
Service(s) Requested: FORTHWITH ORDER: YES (attach minute order) NO
Individual Therapy / Conjoint/Family Therapy / Group Therapy
Psychological Testing / Medication Evaluation / Anger Management
Domestic Violence / Parenting / In-Home Service
Parent’s United / Son’s United / Daughter’s United
ADDITIONAL CLIENT
Client Name: / Date of Birth: / SSN:
Caregiver Name (if applicable): / Caregiver Relationship: / Mother’s First Name:
Client/Caregiver Address: / Client’s Telephone:
Primary Language: / Disability: Yes No / Gender: Male Female / Marital Status:
Birth Place: / Highest Level of Education: / Ethnicity: / Hispanic
Non-Hispanic
Child’s First Removal Date: / Type of Transportation:
Personal Public / Asked Client if a Victim of Crime Report Was Filed?
Yes Claim Number: No

Confidential Patient Information, see Welfare & Institutions code section 5328

Case Name (mother’s name):
Client Currently Participating in Services? NO YES If yes, Type of Service: N/AIndividual TherapyPsychological TestingDomestic ViolenceConjoint/Family TherapyMedication EvaluationParentingGroup TherapyAnger ManagementIn-Home ServiceParent's UnitedSon's UnitedDaughter's United
Provider’s Name: / Agency:
Provider’s Address: / Provider’s Phone:
Service(s) Requested: FORTHWITH ORDER: YES (attach minute order) NO
Individual Therapy / Conjoint/Family Therapy / Group Therapy
Psychological Testing / Medication Evaluation / Anger Management
Domestic Violence / Parenting / In-Home Service
Parent’s United / Son’s United / Daughter’s United
CASE INFORMATION AND SYMPTOMS (new or additional):
APPROVAL SIGNATURES:
** Minute Order, IEP, MHST and other pertinent documents must be attached**
Social Worker’s Signature:
X / Date Requested:
Social Service Supervisor’s Signature:
X / Date of Approval:
ACT Clinician Signature:
X / Date of Consultation:

Confidential Patient Information, see Welfare & Institutions code section 5328