Your browser does not support JavaScript
 
Mental Health Referral Form

MENTAL HEALTH
REFERRAL FORM

 

Referring Information
Was permission from guardian of the child received?
select
Person Making Referral
Referrer Phone
Referral Location (Name of School, Clinic, Hospital, Agency, etc.)


Child Information
Child's Name
Child's Date of Birth (MM/DD/YYYY)
Child's Social Security Number
Child's School
Child's Grade
Child's Gender
select
Child's Race
select
Child's Ethnicity
select


Guardian Information
Does the County have Custody?
select
Caseworker Name & Phone
Guardian Name
Relationship to Child
Primary Cell Phone
Home Landline
Email Address
Street Address
City
State
select
Zip Code


Insurance Information
Does the Child have Medicaid?
select
Medicaid Plan Name
select
If other, please specify:
Medicaid Number (MMIS) – 12 digits
Medicaid Member ID – 11 digits
Does the Child have other Insurance
select
Insurance Carrier
Policy Number
Group Number
Insurance Carrier Phone
Policy Holder Name
Policy Holder Relationship to Child
Policy Holder Phone
Policy Holder Street Address
City
State
select
Zip Code
Date of Referral


Symptoms
Check any symptoms or behaviors that apply to this child
select
Is there a current concern regarding substance abuse?
select
If yes, specify substance(s):
Describe child’s problem and/or other concerns:

 
STAY IN TOUCH Help us transform more children's lives.
Join our newsletter





The Children's Home of Cincinnati

Pages

Our Services
Our Organization
Our Results
Connect
Careers

Support

Donate
Physician Referrals
Contact Us
Privacy Policy
Terms & Conditions

Find Us

The Children's Home of Cincinnati
5050 Madison Road
Cincinnati, OH 45227
(513) 272-2800



© 2017. The Children’s Home of Cincinnati. All Rights Reserved.