Referral for Therapeutic Behavioral Services Spa 3

Referral Manager:

Referral Coordinator:

Email: Referral Date: Client Information Client Name: Age: DOB: Gender M F

Medi-Cal Social Security Number: Number: MIS#:

African/American Asian/American/Pacific Islander Bi-Racial Ethnicity: Hispanic Native American Caucasian Other: Current Residence

Bio Family Hm Foster Home Community Group Home Residential/RCL Other Caregiver: Legal Guardian: Current Address: City, State, Zip: Tel.#: Alt.Tel.# Primary Language Spoken in the Home: At placement since: Total # of placements: School Information School: Tel.# IEP NPS Address: District: Grade: Referring Party Name: Tel.#: Ext Fax #: Relationship to client: E-Mail:

Current Mental Health Provider Clinician: Tel.# Ext. Fax. #:

Agency/ Program Rpt Unit: E-Mail Services currently being provided and frequency of services:

Social Service/Attorney information CSW Name: Phone: Notified of Referral: Yes No Fax: Minor’s Attorney Name: Phone: Notified of Referral: Yes No Fax:

Probation Officer Name: Phone: Notified of Referral: Yes No Fax: Medication Is client currently prescribed medication? Yes No Is client compliant with taking meds? Yes No

Medications/ dosage: TBS is needed to: (check one) Referral for Therapeutic Behavioral Services Spa 3

To prevent psychiatric hospitalization To enable transition to a lower level of care To prevent placement in a higher level of care Current placement is in jeopardy

Describe client’s current situation and reason for requesting TBS Services:

Certified Class Membership (Check all that apply)

In RCL 12 or above Being considered for RCL 12 or above

At risk of hospitalization Previously received TBS, if yes, give date(s) Dates Agency Psychiatric Hospitalization in preceding 24 months* *If yes, give date(s) and number of times hospitalized Hathaway-Sycamores hereby certify that the child/youth is a member of the Certified Class for TBS. Signature of LPHA: Date:

Current Diagnoses Code: Code:

Current Behaviors for TBS to Address PHYSICAL AGGRESSION: Throwing objects Hitting Kicking Spitting Choking Others Pushing Head Banging Property destruction Self-injurious behavior Biting Slapping Dangerous behaviors Posturing/threatening gestures Other:

Frequency: Per day week Level of behavior: Mild Moderate Severe Location: Home School Community

VERBAL AGGRESSION: Profanity/cursing Tantrums Yelling/Screaming Crying Provoking others Intimidating voice Explosive verbal outburst Threats of harm Frequency: Per day week Level of behavior: Mild Moderate Severe Location: Home School Community

OPPOSITIONAL BEHAVIOR: Refusing to remain in safe designated area Medication refusal School refusal Refusing to remain in safe designated area Refusal to follow or complete AM/PM routine Refusal to follow reasonable adult request Other:

Frequency: Per day week Level of behavior: Mild Moderate Severe Location: Home School Community

OTHER CRISIS BEHAVIOR: Cutting Ingesting harmful substances Other: Frequency: Per day week Level of behavior: Mild Moderate Severe Location: Home School Community

Signature of Referring Person: Date: Requested TBS Schedule School Home Monday Thursday Sunday Referral for Therapeutic Behavioral Services Spa 3

Tuesday Friday Wednesday Saturday

Please attach a copy of the child’s current: DMH Client Care / Coordination Plan or other Service Plan / Treatment Goals if non-DMH agency with date and signatures DMH Initial Assessment (9 Page) or other assessments if non- DMH agency with date and signature DMH Payer Financial information & Addendum Minute Order if child is a dependent of the Court Copy of Medical Card 9/06/16