<p> Referral for Therapeutic Behavioral Services Spa 3 </p><p>Referral Manager: </p><p>Referral Coordinator: </p><p>Email: Referral Date: Client Information Client Name: Age: DOB: Gender M F</p><p>Medi-Cal Social Security Number: Number: MIS#: </p><p>African/American Asian/American/Pacific Islander Bi-Racial Ethnicity: Hispanic Native American Caucasian Other: Current Residence</p><p>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: </p><p>Current Mental Health Provider Clinician: Tel.# Ext. Fax. #: </p><p>Agency/ Program Rpt Unit: E-Mail Services currently being provided and frequency of services: </p><p>Social Service/Attorney information CSW Name: Phone: Notified of Referral: Yes No Fax: Minor’s Attorney Name: Phone: Notified of Referral: Yes No Fax: </p><p>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</p><p>Medications/ dosage: TBS is needed to: (check one) Referral for Therapeutic Behavioral Services Spa 3 </p><p>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</p><p>Describe client’s current situation and reason for requesting TBS Services:</p><p>Certified Class Membership (Check all that apply)</p><p>In RCL 12 or above Being considered for RCL 12 or above</p><p>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:</p><p>Current Diagnoses Code: Code:</p><p>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: </p><p>Frequency: Per day week Level of behavior: Mild Moderate Severe Location: Home School Community</p><p>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</p><p>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: </p><p>Frequency: Per day week Level of behavior: Mild Moderate Severe Location: Home School Community</p><p>OTHER CRISIS BEHAVIOR: Cutting Ingesting harmful substances Other: Frequency: Per day week Level of behavior: Mild Moderate Severe Location: Home School Community</p><p>Signature of Referring Person: Date: Requested TBS Schedule School Home Monday Thursday Sunday Referral for Therapeutic Behavioral Services Spa 3 </p><p>Tuesday Friday Wednesday Saturday </p><p>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 </p>