Referral Source Information Section

Briefly describe the reason you are making this referral including specific behaviors, emotions, challenges at home or school and other symptoms. *

Full name of the person completing & submitting this referral. *

Phone Number or the person completing & submitting this referral. *

Email Address of the person completing & submitting this referral. *

Relationship of person making referral to the Child or Youth: *

Parent or Guardian

Foster or Kinship Parent

CPS Worker

Child Placing Agency Staff

Child or Youth's Therapist

Child or Youth's Teacher or School Administrator

Child or Youth's Primary Care Physician

OCOK Staff

OtherOther

Is this the first time you have made a referral to CKBH?

Yes

No

How did you hear about CK Behavioral Health

I discovered CKBH using an online search tool like Google or Yahoo

I discovered CKBH when someone handed me a flyer or brochure

I discovered CKBH on Facebook through a shared post or ad

Word of mouth: A supervisor, coworker, or other professional introduced me to CKBH

OtherOther

Thank you for continuing to make referrals to CKBH. We would love to hear your feedback regarding the referral process. We understand that this may not be the best time for you, but if you have a moment please feel free to type a few comments regarding your experience in referring to CKBH or any suggestions you have for ways we can improve. Thank you!

Service Delivery Method

CK Behavioral Health provides services through two methods; 1) Traditional through which our staff and client are in the same room at the same time or, 2) Telehealth where our staff visit with our client via secure video calls (involving a smartphone, tablet, or computer) to provide services.

Please indicate your preference below. *

Telehealth Only

Traditional In-Person Only

Combination of Telehealth and Traditional

No Preference

OtherOther

Note: While we began offering our services via telehealth as a way to meet the needs of our community during the COVID pandemic; we are excited to have expanded our capacity and have added it as a permanent method for service delivery even beyond the period of the pandemic.

If the client lives in an area that we unable to serve via Traditional In-Person services do you want to try Telehealth?

Yes

No

We are continuously working to ensure sufficient capacity to meet the behavioral health needs of the communities we serve; however, if our staff for a given area is full at the time of your referral we would like the opportunity to serve you via telehealth, if appropriate.

Child or Youth Information Section

CPS Conservatership Worker's Full Name

Parent/Legally Authorized Representative Information Section

CPS Conservatership Worker's Phone Number

CPS Conservatership Worker's Email Address

Is the Child/Youth at risk to experience placement or school disruption, abuse, neglect or exploitation? *

N/A

Child/Youth is at risk of being kicked out, removed, or disrupted from their current residence.

Child/Youth is at risk of experiencing suspension or expulsion from school.

Child/Youth is at risk of experiencing abuse, neglect or exploitation.

Please check all that apply.

Has the child or youth experienced psychiatric hospitalization in the past 90 days? *

Yes

No

Longest stay (in days) in psychiatric hospital in the past 90 days.

How many separate admissions to psychiatric hospital has the Child or Youth experienced in the past 90 days?

Has the Child or Youth experienced any crisis episodes in the past 90 days? *

Yes

No

Examples include (but are not limited to): emergency room visits, 23 hour observation periods, need for mobile crisis response, emergency respite, etc . . .

Please list and describe all crisis episodes that have occurred in the past 90 days.

Has the Child or Youth had any involvement with Juvenile Justice in the past 30 days? *

Yes

No

Please list and describe any involvement with Juvenile Justice.

Child Risk Behaviors (Occurring during the past 30 days) *

Please check all that apply.

Please provide a description for any Child Risk Behavior items checked. *

Severe Emotional, Behavioral, or Mental Health Needs (Occurring during the past 30 days) *

Please check all that apply.

Please provide a description for any Severe Emotional, Behavioral, or Mental Health Need items checked. *

CK Behavioral Health Referral Form

Referral Source Information Section

Service Delivery Method

Child or Youth Information Section

Parent/Legally Authorized Representative Information Section

Foster or Adoption Family Home Information Section

Kinship Family Home Care Information Section

Our Community Our Kids (OCOK) Information Section

Child Protective Services Information Section

Child or Youth's Risk Screening Section

Child or Youth's Treatment History Information Section

CK Behavioral Health Referral Form

Referral Source Information Section

Service Delivery Method

Child or Youth Information Section arrowup5

Parent/Legally Authorized Representative Information Section arrowup5

Foster or Adoption Family Home Information Section arrowup5

Kinship Family Home Care Information Section arrowup5

Our Community Our Kids (OCOK) Information Section arrowup5

Child Protective Services Information Section arrowup5

Child or Youth's Risk Screening Section

Child or Youth's Treatment History Information Section

Child or Youth Information Section

Parent/Legally Authorized Representative Information Section

Foster or Adoption Family Home Information Section

Kinship Family Home Care Information Section

Our Community Our Kids (OCOK) Information Section

Child Protective Services Information Section