LINK-KID CAC REFERRAL FORM

First Name:

Last Name:

Date of Birth:

Gender: --None-- Male Female Transgender

Language Spoken at Home: --None--English Spanish French African Dialects American Sign Language Arabic Armenian Bilingual Brazilian Portuguese Burmese Dialects Cantonese Cape Verdean Creole Haitian Creole Hmong Italian Khmer / Cambodian Mandarin Chinese Mondolvin Other Portuguese Russian Vietnamese

Language Preference for Services: --None-- English Spanish French African Dialects American Sign Language Arabic Armenian Bilingual Brazilian Portuguese Burmese Dialects Cantonese Cape Verdean Creole Haitian Creole Hmong Italian Khmer / Cambodian Mandarin Chinese Mondolvin Other Portuguese Russian Vietnamese

Legal Custody Status: --None-- Both Parents Mother Father Department of Children & Families Shared - DCF & Parents Self Other

Race/Ethnicity: --None-- American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White

LGBTQ: --None-- Yes No

Phone #:

Street:

City:

State/Province: --None-- Alaska Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

ZIP/PostalCode:

Email:

Current Living Status: --None-- Home with Parent(s) Juvenile Justice Setting Foster Care Friends Jail Kinship Foster Care Medical Hospital Other Psych Hospital Residential Treatment / Congregate Care Shelter With Relatives

First Name:

Last Name:

Street:

City:

State/Province: --None-- Alaska Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

ZIP/Postal Code:

Phone:

Language: --None-- English Spanish French African Dialects American Sign Language Arabic Armenian Bilingual Brazilian Portuguese Burmese Dialects Cantonese Cape Verdean Creole Haitian Creole Hmong Italian Khmer / Cambodian Mandarin Chinese Mondolvin Other Portuguese Russian Vietnamese

Email:

Relationship to Youth: --None--Adoptive Parent DCF Father Foster Parent Grandparent Mother Relative Social Worker Step-Parent CAC

First Name:

Last Name:

Street:

City:

State/Province: --None-- Alaska Arkansas Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming

ZIP/Postal Code:

Phone:

Language: --None-- English Spanish French African Dialects American Sign Language Arabic Armenian Bilingual Brazilian Portuguese Burmese Dialects Cantonese Cape Verdean Creole Haitian Creole Hmong Italian Khmer / Cambodian Mandarin Chinese Mondolvin Other Portuguese Russian Vietnamese

Email:

Relationship to Youth: --None--Adoptive Parent DCF Father Foster Parent Grandparent Mother Relative Social Worker Step-Parent CAC

First Name:

Last Name:

Phone:

Email:

Relationship to Youth: --None-- Adoptive Parent CAC DCF Father Foster Parent Grandparent Mother Pediatrician or medical provider Relative School provider Self Social Worker Step-Parent Other (please specify)

How did you hear about LINK-KID?: --None-- School Medical Provider or Staff DCF CAC/DA Behavioral Health Help Line (BHHL) DMH Other

First Name:

Last Name:

Email:

Phone:

Primary Insurance: --None-- Aetna Beacon Strategies (BMC Healthnet) Behavioral Health Systems Blue Cross / Blue Shield Boston Healthnet Children's Medical Insurance Plan Cigna CMSP Commercial BC/BS Fallon GIC Harvard Pilgrim Heath New England Magellan Managed Health Network MassHealth MassHealth Beacon MassHealth BMC MassHealth Fallon MassHealth HMO MassHealth MBHP MassHealth Neighborhood MassHealth Network MassHealth NHP MassHealth PCC MassHealth Standard MassHealth Tufts MBHP Medicaid Medicare/Medicaid Neighborhood Health Plan Network Health Pacificare/UBH TRICARE Tufts Unicare Unicare GIC Beacon United Behavioral Health United Healthcare Victims Comp Wellness Corp. Other (please specify)

Primary Insurance Policy #:

Policy Holder Name:

Policy Holder DOB:

Secondary Insurance: --None-- Aetna Beacon Strategies (BMC Healthnet) Behavioral Health Systems Blue Cross / Blue Shield Boston Healthnet Children's Medical Insurance Plan Cigna CMSP Commercial BC/BS Fallon GIC Harvard Pilgrim Heath New England Magellan Managed Health Network MassHealth MassHealth Beacon MassHealth BMC MassHealth Fallon MassHealth HMO MassHealth MBHP MassHealth Neighborhood MassHealth Network MassHealth NHP MassHealth PCC MassHealth Standard MassHealth Tufts MBHP Medicaid Medicare/Medicaid Neighborhood Health Plan Network Health Pacificare/UBH TRICARE Tufts Unicare Unicare GIC Beacon United Behavioral Health United Healthcare Victims Comp Wellness Corp. Other (please specify)

Secondary Insurance Policy #:

Policy Holder Name:

Policy Holder DOB:

Primary Care Physician:

Primary Care Physician Phone:

Other Providers Involved:

Other Provider Telephone:

Family involved with court system?: --None-- Yes No

Name of School:

Grade:

Dev. Delay / Int. Disability:

Mental Health/Axis I Diagnosis:

EBT Referred For (Control + click to select multiple values): TF-CBT ARC PCIT CPP EMDR AF-CBT PSB-CBT

Service Type: (Control + click to select multiple values) Outpatient In-Home Therapy

Appointment Preference (Control + click to select multiple values): Mornings Afternoons Evenings

Service Setting (Control + click to select multiple values): In Person Only Telehealth Hybrid - In Person & Telehealth

Access to transportation for treatment?: --None-- Yes No

Other possible barriers to treatment:

History of Related Trauma and Behaviors:

Trauma Screen: History: (Control + click to select multiple values) Physical Abuse Sexual Abuse Engaged in Prostitution Victim of Commercial Sexual Exploitation (CSEC) Emotional Abuse School Violence/Bullying Domestic Violence Violence in neighborhood War/Terrorisim/Immigration Natural Disaster Lost Loved-one due to death, divorce, or abandonment Parent Incarcerated Separated from parents/caregivers Parental Substance Abuse Parent history of trauma Parent Mental Illness Frequent Moves Homelessness Neglect Systems-Induced Trauma (i.e. Removal multiple placements) Been in a severe accident or have/had severe illness Been kidnapped Parent Deployed Traumatic grief (e.g. great difficulty moving through stages of grief) Other (please explain)

Current Reactions/Behaviors: (Control + click to select multiple values) Oppositional Behaviors Depression Self-Harm Dissociation Impulsivity Attention/concentration Conduct Problems Anxiety Anger Problems Regression Somatization/Physical Prob w/ Emotional Reg Attach/relationship Suicidal Ideations Homicidal Ideations Audio Hallucinations Sleep Difficulties Sexualized Behaviors Animal Cruelty Visual Hallucinations Other (please explain)

Current Post-traumatic Stress Reactions: (Control + click to select multiple values) Re-experiencing (nightmares, flashbacks or intrusive thoughts) Avoidance (not want to talk about the trauma, avoiding trauma reminders) Numbing (lack of emotion, social withdrawal) Hyperarousal (exaggerated startle response(s), hyper-vigilance, being "on edge")