Date Referral Form Received at BPCC:______ - Brewer

Agency Referral Form
Brewer-Porch Children's Center
Box 870156
University of Alabama
Tuscaloosa, AL 35487-0156
Phone (205) 348-7236; Fax (205) 348-9368
PROGRAM TO WHICH REFERRAL IS BEING MADE:
 Adolescent Adaptive Skills Training Program
 Outpatient Day Treatment Program
 Short Term Treatment and Evaluation Program
 Moderate Residential Program
 Community Autism Intervention Program
 Intensive Residential Treatment Program
 Therapeutic Foster Care
Child’s Full Name:____________________________________________________________________
Last
First
Middle
Nickname
Birthdate:___________________
Age: ___________ Sex: __________ Race: _______________
Social Security #:_________________________
Native Language Spoken at Home:______________
Legal Guardian:_____________________ Phone: H (_____)_____________ W (_____)_____________
Address:_______________________________ Relationship to Client:__________________________
Parent (s): ________________________ Phone: H (_____)_____________ W (_____)_____________
Address:__________________________ Place of Employment:_______________________________
Child Resides With:(Name)__________________ Phone: H (_____)____________W (____)_________
REFERRAL/CLINICAL INFORMATION:
Check reason for referral to Brewer-Porch Children's Center:
( ) poor self-control
( ) cruelty to animals
( ) inappropriate aggressive
behavior/hostile tantrums
( ) hyperactivity
( ) running away
( ) destructiveness
( ) poor school performance
( ) truancy
( ) defiance of authority
( ) manipulative behavior
( ) sexual maladjustment
( ) assaultive behavior
( ) child abuse victim
( ) sexual abuse
( ) dysfunctional family
relationships
( ) enuretic
( ) encopretic
( ) withdrawn/regression/confusion
( ) moderate to severe depression
( ) moderate to severe anxiety
( ) homicidal ideation
( ) suicidal ideation
( ) inadequate social skills/
poor interpersonal skills
( ) drug experimentation
( ) irrational fears
( ) other: __________________ ( ) ____________________
(
(
(
(
(
(
(
(
(
) low frustration tolerance
) inappropriate attention seeking behavior
) inadequate problem solving skills
) in need of 24 hour protective oversight
and supervision in daily living
) impaired reality contact-e.g., hallucinations,
delusions, ideas of reference
) disabling somatic symptoms
) medication compliance
) poor socialization skills
) inpatient care is not warranted
( ) _____________________________
Explain checked items and include any recent precipitating events:______________________________
____________________________________________________________________________________
____________________________________________________________________________________
BPCC Referral Form
Has client ever received treatment from another mental health organization?  Yes  No If yes, check type
of service and provide details below. Indicate age mental health treatment first began: __________
 Outpatient/Counseling  Outpatient/Psychiatric  Case Management  In-home intervention
 Day Treatment  Residential  Inpatient  Emergency After Hours  Other:________________
Dates
Type of Treatment
Agency and Address
Outcome/Diagnosis
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Does the child exhibit developmental delay/disorder?
Yes
No If yes, check type:
Mental Retardation
Autism
other Pervasive Developmental Disorder, type________________
Other developmental delay, describe:___________________________________________________
If child has diagnosis of Autism or other Pervasive Developmental Disorder, who made the
diagnosis? _______________________
When? __________________________________
What previous services and/or evaluations for Autism/PDD or other developmental delay/disorder has your
child received?___________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Does your child have other areas of functioning you feel may need further evaluation (e.g., medication
issues, educational needs not met )?__________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
If applicable, check and date this child’s current court status:
Dependent _______
CHINS _________
Delinquent _________
Adjudicated ________
Pending court action for custody________
Other:__________________________________________________________________________
FAMILY INFORMATION:
Is the family aware of their child’s problem?
Yes
No
Were family members informed/involved with this referral?
Yes
No Date Discussed: ________
To what degree do you think the family will participate regarding evaluation/treatment of their child?
Why?______________________________________________________________________________
___________________________________________________________________________________
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BPCC Referral Form
List information regarding people living in client’s current home:
Name
Relationship
Age
Name
Relationship
Age
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
______________________________________________
List additional family members or significant others with whom client has contact:
Name
Relationship
Age
Name
Relationship
Age
______________________________________________
______________________________________________
______________________________________________
______________________________________________
EDUCATION INFORMATION:
Current School:________________________________ Teacher:__________________ Grade:______
Address:______________________________________________ Phone:_______________________
If not in school please give reason and last school attended:___________________________________
___________________________________________________________________________________
Is child
Special Ed?
504?
N/A
If Special Ed/504, check applicable:
Classroom Placement:
Regular
Date of Last IEP/504:_________
Unknown Date Special Ed/504 services began:___________
MR
ED
Monitoring
LD
DD
Resource
OHI
Unknown
Self Contained
Other:________
Unknown
Academic Functioning: Reading ____ Math_____ Spelling_____
Alternative school placements?
Explain:__________________________________________________________________________
___________________________________________________________________________________
Previous Schools: ____________________________________________________________________
___________________________________________________________________________________
Any Grades Repeated?
No
Yes If yes, which grade(s):_________________________________
Reason:____________________________________________________________________________
Any Disciplinary Action/Suspensions/Expulsions? Explain:____________________________________
_________________________________________________________________________________________________________________
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BPCC Referral Form
MEDICAL INFORMATION (Please include copy of last physical. Current physical required for STTEP
and Residential):
Medicaid:
All-Kids:
Yes
Yes
No
No
Other Medical Insurance:
Medicaid #:_______________________
All-Kids #: _______________________
Yes
No
Name as appears on card:________________________
Insurance Company:___________________ Policy #:_______________ Group #:_____________
Allergies:
Height. ________ Eye Color _____________
Weight. ________ Hair Color _____________
No Known Allergies (NKA)
Medications _______________________________________
Food ____________________________________________
Other ____________________________________________
Developmental History
Birth Wt. __________
Child was born:
Full Term
Delivery:
Normal
Early: #of weeks______
Problems ________________
Late : # of weeks_____
Condition at birth:
Normal
Jaundice
Injury, describe:_____________________________________________________
Other:________________________________
Milestones (Record Approximate Age):
Difficulties in toilet training:
Yes
No
Sat alone
___________
Spoke in Sentences
___________
If yes, describe:_____________________________________
Walked alone ___________
Toilet Trained
___________
Said Words
___________
Dressed Self
___________
Current : Enuresis: Daytime
Yes
No
: Encopresis: Daytime
Yes
No
If yes, describe:_____________________________________
Medical History:
Measles
Mumps
Chicken Pox
Whooping Cough
Asthma
Short of Breath
Pneumonia
Kidney Problems
Eye Problems
Hearing Problems
Speech Problems
Age
______
______
______
______
______
______
______
______
______
______
______
Birth Defects
Meningitis
Lead Poisoning
Ingested Poison
Headache
Dizziness/Fainting
Clumsiness
Heart Palpitations
Chest Pain
Heart Murmur
GI Problems
Age
______
______
______
______
______
______
______
______
______
______
______
Broken Bones
Anemia
Head Injury
Brain Damage
Ear Infections
High Fever
Tonsillitis
Seizures
Skin Problem
Diabetes
Age
______
______
______
______
______
______
______
______
______
______
Other: Explain below
Comments: Explain any checked boxes:______________________________________________________________________________________
______________________________________________________________________________________________________________________
Current Medical Problems:
No
Yes Describe:
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
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BPCC Referral Form
Sleep Pattern:
Sleep Difficulty:
Yes
No
If yes, mark the following:
Difficulty falling asleep
Awakens frequently
Other ______________
# of hours: __________
Bedtime: __________
Awakens early
Sleep aids
Hospitalizations/Surgeries:
Name of Hospital
Date Admitted
Doctor
Reason for Admission
______________________________________________________________________
Psychiatric
Medical
Describe:_________________________________________________________________________________________
______________________________________________________________________
Psychiatric
Medical
Describe:_________________________________________________________________________________________
______________________________________________________________________
Psychiatric
Medical
Describe:_______________________________________________________________________________________________________
Immunizations:
Up to Date:
Yes
No
Date of Last Tetanus: Month _________________
Copy of Immunization Record:
Yes
Year __________________
No
Current Medications (Prescription, Over the Counter, Inhalers, Supplements):
Name
Dose
Frequency
Indication
Last Dose
Prescribing Physician
Side Effects
Previous Psychotropic/Mental Health Medications:
Name
Dose
Frequency
Indication
Prescribing Physician
Side Effects
Last Dose
Client Substance Use History
N/A
Smoke
Alcohol
Drug Use
Packs/Day __________________
No. of Years _________
Type _______________ Amount _______________ No. of Years _________
Type _______________ Amount _______________ No. of Years _________
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BPCC Referral Form
Please list all medical problems and/or exceptionalities (language, speech, hearing, weight, allergies, size,
appearance, physical limitations, etc):____________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Is there a need for an interpreter
Yes
No. If yes explain _____________________________________
Primary Physician:_________________________
Phone:_____________________________
Other Risk Factors: Please check which factors, if any, might place this child at increased risk if he/she
required crisis intervention involving physical restraint or seclusion:
History of abuse/trauma
Cultural
Medical condition
Language barrier
Physical disabilities
Please explain: _____________________________________________________________________________
__________________________________________________________________________________________
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BPCC Referral Form
Basic Living Skills Identification
Child’s Name: _______________________________________
Date: _____________________
Name of person(s) completing the form: _____________________ Relationship to Child: ____________
______________________
____________
Please check areas in which the child needs basic living skills.
Personal Hygiene _______
Child needs improvement with independently dressing/undressing
Child needs improvement with toileting skills
Child needs improvement with grooming skills (e.g., brushing teeth, bathing)
Child needs improvement with personal cleanliness, e.g., hand washing
Child needs improvement with complying with Code of Conduct dress code
Other: __________________________________________________________
Meal Preparation ________
Child needs to learn or improve table manners
Child needs to learn how to plan and budget for a meal
Child needs to learn how to prepare basic meals safely and appropriately
Child needs to learn to make appropriate menu choices
Child needs to learn to set and/or clear the table correctly
Other: __________________________________________________________
Housekeeping/Tidiness______
Child needs improvement with laundry skills
Child needs improvement with keeping things neat at home (e.g., making beds, picking up clothing).
Child needs improvement keeping things clean (e.g., cleaning toilet)
Child needs improvement with keeping work area straight
Other: ___________________________________________________________
Healthy Lifestyle _______
Child needs improvement in the area of nutrition
Child needs improvement in his/her fitness level
Child needs improvement in competitive and non-competitive recreation
Child needs improvement in the area of sexual education
Child needs improvement in the area of First Aide
Child need improvement with knowledge of drug and alcohol issues (health and legal consequences)
Other ___________________________________________________________
Stress Management _________
Child needs improvement in learning and using alternatives to tantrums and/or aggression when angered
(e.g., instead of hitting, Child talks about feelings)
Child needs improvement in learning and using appropriate ways of controlling anxiety or “nerves”
Child needs improvement in not withdrawing from situations when they become stressful and/or difficult
Child needs improvement with tolerating frustration and/or delaying gratification
Child needs improvement with stopping and thinking before acting implusively
Other: ___________________________________________________________
Communication _________
Child needs improvement in expressing his/her wants and needs appropriately
With peers
With adults
Child needs improvement in understanding when others are speaking to him/her
With peers
With adults
Child needs improvement expressing basic needs in written form
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BPCC Referral Form
Child needs improvement reading and understanding simple communications (e.g., notes, signs,
directions, reading a menu)
Other ___________________________________________________________
Social Skills __________
Child needs improvement initiating positive interactions
With peers
With adults
Child needs improvement responding when others try to interact with him/her
Child needs improvement making appropriate eye contact with others
Child needs improvement getting along with others
With peers
With adults
Child needs improvement recognizing and/or understanding his/her feelings
Child needs improvement recognizing and/or understanding feeling of others
With peers
With adults
Child needs improvement behaving appropriately given the social situation (e.g., not speaking loudly in
church)
Other ___________________________________________________________
Community Awareness _______
Child needs help in understanding how to be a responsible citizen
Child needs help understanding community rules and laws
Child needs help understanding when a situation is dangerous and what to do in those situations (e.g.,
strangers, bad weather)
Child needs improvement identifying community recreational and leisure resources
Child needs help understanding community services available and how to access them
Child needs improvement with identifying job opportunities and employment possibilities in the community
Other ___________________________________________________________
Medication Management _______
Child needs improvement learning to take medication, and understanding the benefits and side effects of
medication
Child needs to learn to visually recognize prescribed medication
Child needs improvement identifying effects of medications on themselves
Child needs improvement identifying frequency, time, and dosage of own medications
Child needs improvement with self-administration of meds
Other ___________________________________________________________
Money Management ________
Child needs improvement in recognizing coins and paper money and the function of money
Child needs improvement in understanding basic math skills involved in counting change and making
purchases
Child needs improvement in planning and saving for a particular purpose (i.e., budgeting)
Other ___________________________________________________________
Patient Education/re: Symptoms _______
Child needs improvement with identifying own symptoms and behavior problems
Child needs improvement in understanding how his/her behaviors/symptoms affect themselves
Child needs improvement in how to cope effectively with behaviors/symptoms
Other ___________________________________________________________
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BPCC Referral Form
TO EXPEDITE REFERRAL:
Attach copies of cumulative records/transcripts, report cards/grades, attendance records, special
test/counseling reports, psychological testing, contacts with school authorities, IEP, social summaries, etc. (if
applicable)
Please include or attach any other comments, material, or information that may assist us in understanding and
helping this child.
____________________________________
Signature of person completing the form
________________________
Position / Relationship
__________
Date
Phone Number:_______________________
Referral Agency:
Department of Human Resources, County:________________________________
School System: ____________________
Community Mental Health Center:_________________
Other:________________________________
If this is DHR referral:
Case #:________________ Child’s Eligibility Status: Type_______________ Code #_______________
*********************************************************************************************
For BPCC Use Only
Date Referral Form Received at BPCC:____________
Educational Materials
Report Card
IQ Test Results
Academic Testing Results
IEP
_______________________
BPCC Case #________________________
Medical Information
Physical Exam
Insurance Information
Psychiatric Reports
Immunization Records
_________________________
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Miscellaneous
Birth Certificate
Psychosocial Summary
Psychological Evaluation
Social Security Card
Medicaid Card
_____________________