Referral Therapeutic Day Treatment Services

Referral/Client Screening Form

Referral Date
 /  / 
Person/Agency Referring
Child/Youth Name
Gender
Race
DOB
 /  / 
SSN
Telephone Number
-
Address:
School
Grade
Special Education
1/4
Probation Officer
DSS Social Worker
Physician
Physician Telephone Number
-
Physician Address
Psychiatrist
Psychiatrist Phone Number
-
Psychiatrist Address
Other Professional(s) Involved
2/4
Medication(s) and Dosage(s)
Medicaid Number
Other Insurance
Parent/Guardian Name
Parent/Guardian Telephone
-
Parent/Guardian Work Phone
-
Parent/Guardian Cell Phone
-
Parent/Guardian Address
Presenting Problem(s)
3/4

Therapeutic Day Treatment Eligibility Criteria:

Recipients of Therapeutic Day Treatment must have the functional capability to understand and benefit from the required activities and counseling of this service.  These services are rehabilitative and intended to improve the client’s functioning.  It is unlikely that individuals with severe cognitive and developmental delays/impairments would clinically benefit and meet the service eligibility criteria.

Children and adolescents must demonstrate a clinical necessity for the service arising from a condition due to a mental, behavioral, or emotional illness that results in significant functional impairments in major life activities.

Individuals must meet both criteria

Has disability become more disabling over time? *
Does the individual require significant intervention through supportive, intensive services offered over a protracted period of time? *

Individuals must meet at least two (2) of the following on a continuing or intermittent basis:

Does the individual have difficulty in establishing or maintaining normal interpersonal relationships to such a degree that they are at risk of hospitalization or out-of-home placement because of conflicts with the family or community? *
Does the individual exhibit such inappropriate behavior that repeated interventions by mental health, social services, or judicial system are necessary? *
Does the individual exhibit difficulty in cognitive ability such that they are unable to recognize personal danger or recognize significantly inappropriate social behavior? *

In addition to meeting two of the three criteria listed above, children and adolescents must meet one (1) of the following:

Does the individual require year-round treatment in order to sustain behavioral or emotional gains? *
Does the individual have behavioral and emotional problem s are so severe they cannot be handled in self-contained or resource emotionally disturbed (ED) classrooms without this programming during the school day or as a supplement to the school day or school year. *
Would the individual otherwise be placed on homebound instruction because of severe emotional or behavioral problems, or both, that interfere with learning? *
Does the individual have deficits in social skills, peer relations, or dealing with authority; are hyperactive; have poor impulse control; or are extremely depressed or marginally connected with reality? *
If the child is in in preschool enrichment and early intervention programs, are the child’s emotional or behavioral problems, or both, so severe that they cannot function in these programs without additional services? *
Referring Individuals Digital Signature
Todays Date
Word Verification:
4/4

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