Orange County System of Care Referral
 
Instructions:
1.) Must complete the Authorization form at this  Link  and Fax in to 845-291-2628
2.) In trying to respond to your referral in a timely manner, OCSOC partners with our Mobile Mental Health team to provide wellness visits following a hospital discharge or when unable to reach you by phone. This service will be provided with respect & consideration.
I accept this policy
3.) Complete all Applicable Information below.
4.) Click "Submit" to send referral to Orange County System of Care. Pink Fields are required.
5.) Questions? Call 845-360-6710
Referral Date: 9/23/2017

Youth/Young Adult Information
First Name: Middle Name: Last Name: Suffix:
Date of Birth:
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Age: 0 Gender:
Address:
Address 2:
Address 3:
City: State: Zip: Search For Zip Code Fill City and State from Zip Copy client address to Primary Parent/Guardian Address
County of Residence:  Check if mailing address is different than address:

Phone Home: Phone Cell: Phone Work:
Youth Email Address:

Is youth/young adult in school?

Primary Parent/Guardian Information
First Name: Middle Initial: Last Name:
Address:
Address 2:
Address 3:
City: State: Zip: Search For Zip Code Fill City and State from Zip
County of Residence: Check if mailing address is different than address:

Phone Home: Phone Cell: Phone Work:
Email Address: Preferred method of contact:
Relationship to Youth:

Is this the legal guardian? Does parent/caregiver live with youth/young adult?

Referring Person Information
The person completing this form must enter their name and phone number in the required sender section below so we may contact you if we need additional information.
Agency or individual who is referring youth/young adult to SOC:
First Name:   Last Name:
Position/Title:   Email:
Home Phone: Cell Phone: Work Phone: Fax:
Preferred Phone:
Agency Name:

What are the current unmet needs for this youth/young adult? Indicate which, if any, are urgent needs.

Please explain why this youth/young adult requires the highest level of service that the Orange County System of Care provides.
Specify concerns At Home(Ex. Safety Concerns for youth and/or family, rebellious, curfew violations, physical aggression, trauma, child welfare/CPS involvement):
Specify concerns In School(Ex. attendance, suspension, altercations, weapons)
Specify concerns In the Community(Ex. known to police, past involvement with crisis services, Juvenile Justice, substance abuse)
Has the youth/young adult experienced a traumatic event?
If yes, what was it? When did it occur?

Services and Placements
Is this youth/young adult currently receiving services?
Is the youth/young adult actively participating in services?

What service systems is the youth/young adult currently involved with? (Select all that apply)

Is the youth/young adult currently in out-of-home placement?

How many times has youth/young adult been incarcerated in the past 12 months? [enter 0 if none]

Educational Services
Does youth/young adult have an Individualized Education Plan(IEP) or 504 Plan?
Comments:
Date of Last IEP:
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Committee on Special Education Status:

School Services:
INSTRUCTIONS: To add School Services, select a value from the ‘Service’ drop-down list (only the ‘Special Ed’ item has additional selections). Once selected, click on “Save Service” link to save the item to the grid. You may add multiple Services by repeating the process.
  ServiceSpecialEd TypeNotes
No records to display.
Service: Notes
Save Service Clear
School History/Difficulties/Issues:


Please check all the problems or concerns that have led you to refer this youth/young adult.
Select at least one below or select from the following:
Risk to Self or Others
01
02
03
04
Symptoms, Clinical Concerns
05
06
07
08
09
10
11
12
13
14
15
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17
18
21
Housing/Placement
19
20
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23
24
25
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27
Social, Peer Interactions
28
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30
31
32
33
Substance Abuse
34
35
Criminal or Delinquent Behavior, Police Involvement
36
37
38
39
40
41
42
43
44
45
46
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50
Physical Health Issues
51
52
School/Education
53
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56
Family Issues
57
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66
67
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72
Child/Youth Concerns
73
74
75
76
77
Other Concerns
78

Destructive Behaviors
Using the Scale below indicate the level that most accurately reflects the frequency with the child engaged in the following behaviors in the past 18 months
Never Rarely Sometimes Often Always Unknown
SCALE
0 NEVER This behavior not observed or reported
1 RARELY The child has engaged in behavior once in the past 18 months
2 SOMETIMES The child has engaged in behavior two times in the past 18 months
3 OFTEN The child has engaged in behavior five times in the past 18 months
4 ALWAYS The child has routinely engaged in behavior more than five times in the past 18 months
9 UNKNOWN
Suicide Attempts
Destruction of property
Fire Setting
Cruelty to Animals

Needs and Challenges
Do youth's problems occur in more than one situation and environment in his/her life?
Did problems begin more than 6 months ago?
Has the severity of symtoms been consistent over time?
Have there been several changes in service provider that have affected child?
Does child need more than weekly behavioral and/or medical intervention?
Does child have transportation needs so that he/she can attend behavioral and/or medical intervention?

Hospital and Emergency Room Use
How many times has youth/young adult used the emergency room in the past 6 months? [enter 0 if none]
Has the youth/young adult ever been hospitalized for mental health reasons?
How many times has youth/young adult been hospitalized in the past 2 years? [enter 0 if none]
How many of these hospitalizations were in the past 12 months? [enter 0 if none]

Diagnosis(DSM) Information
Does youth/young adult have a current mental health diagnosis?  

Axis I Diagnosis: Please list Axis I primary diagnosis first. Up to 3 Axis I diagnoses may be entered.
Axis Ia. DSM Code: Search For Diagnosis Code
Axis Ib. DSM Code: Search For Diagnosis Code
Axis Ic. DSM Code: Search For Diagnosis Code

Axis II Diagnosis: Personality disorders, mental retardation(if any) - up to 2 Axis II diagnoses may be entered.
Axis IIa. DSM Code: Search For Diagnosis Code
Axis IIb. DSM Code: Search For Diagnosis Code

AXIS III: General Medical Condition (ICD-9-CM Codes)
Search For Diagnosis Code
Search For Diagnosis Code
Search For Diagnosis Code
Search For Diagnosis Code
Search For Diagnosis Code

AXIS IV: Psychosocial and Environmental Problems [Select all that apply]

AXIS V: Global Assessment of Functioning (GAF):
Current Score:   Spin UpSpin Down
Date of Diagnosis:
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Who provided diagnosis(select one):

Youth's IQ Range:
Youth's IQ Scores:
Verbal: Performance:
Date of Scores:
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Notes/Additional Information