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Williams/Crawford & Associates

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Make a Referral

Date of Referral

County of Residence

PASSE assigned to identified child

PASSE Care Coordinator Information

Name

Phone Number

Email Address

PASSE Care Coordinator Supervisor's Information

Name

Phone Number

Email Address

Type of Referral

Emergency Referral (24-hour follow-up with referral source)
Regular Referral (48-hour follow-up with referral source)

Date of most recent BH Independent Assessment for identified child

Caregiver #1

First Name

Last Name

Date of Birth

Phone #

Alt. Phone #

Relationship

Caregiver #2

First Name

Last Name

Date of Birth

Phone #

Alt. Phone #

Relationship

Children (identified child with BH needs to be listed first)

First Name

Last Name

Date of Birth

School

Identified child's Medicaid ID number

PASSE ID number (if known)

Current outpatient BH provider

First Name

Last Name

Date of Birth

School

First Name

Last Name

Date of Birth

School

First Name

Last Name

Date of Birth

School

First Name

Last Name

Date of Birth

School

First Name

Last Name

Date of Birth

School

List any additional children/caregivers here:

Family Address

Family should meet all minimum criteria:

At least one child between the ages of 4-17 with an identified BH need for FCT service
A caregiver invested in participating in FCT services
The need to facilitate a successful reunification if the child(ren) are already placed out of the home, or to avoid out of home placement for the child(ren)

Type of case for family:

Prevention of Removal
Reunification
Pre-Post Adoption
Post Residential
Other

Please describe

Preferred Primary Language

Interpreter Services needed?

Yes
No

Comments about family’s need for an interpreter, member-specific, etc.

Referral Behaviors

Please review this list below and add information by any of items which you indicate are present for this family, such as which family member is involved, frequency and last incident.)

Serious family conflict due to abuse and/or neglect

Concerns or problems regarding caregivers and overall family support systems (ex. – Caregiver who is trying to relinquish custody of child to DCFS due to inability to control child’s behavior, etc.)

Mental Health Issues

Serious behaviors including substance abuse, physical aggression, running away, truancy, fire setting

Defiant/Oppositional behaviors

Suicidal/Homicidal/Psychotic behaviors

Juvenile Justice Involvement including unruly/delinquent

Youth displaying problem sexual behaviors (include any prior treatment)

Youth in adoptive placements in danger of disruption

Trauma impacting the family

Concerns/problems regarding caregiver/family support

Youth returning home from residential placement (bypassing step-down programs)

Substance Use problems (which member(s), impact on family functioning)

Repeated acute hospitalizations (please describe where, when, & why briefly)

Other (please describe)

Identify other agencies involved with the family:

Identify family strengths:

Note if any child is in foster care & give placement information:

Other pertinent (please describe):