IICAPS Referral and Critical Information Form. Date of Referral Insurance Insurance # Current Address (must include zip code with address)

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Cornelius Lloyd
5 years ago
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1 Page 1 of 5 IICAPS Site: IICAPS Referral and Critical Information Form Date of Referral Insurance Insurance # Referral Source Telephone Fax Number Date of Discharge From referral source Child's Name Current Address (must include zip code with address) D.O.B. Age M/F Is the Child of Hispanic Origin? (Select only one): Child s Race: (Circle/Highlight all that apply): No, Not of Hispanic, Latino or Spanish Origin Yes, Mexican, Mexican-American, Chicano Yes, Puerto Rican Yes, Cuban Yes, South or Central American Yes, of Hispanic/Latino Origin American Indian or Alaska Native Asian Black or African-American Native Hawaiian or other Pacific Islander White Other Family Telephone Numbers: Work Home Primary Language: Of Child: Of Caregivers: Yes No OCFS Past Worker Phone# Yes No OCFS Current Worker Phone# Residing with and Relationship to IP Guardian Guardian s DOB

2 Page 2 of 5 Mother s Name Age D.O.B. Phone Race/Hisp. Origin (use options listed above) Father s Name Age D.O.B. Phone Race/Hisp. Origin (use options listed above) Child s School Grade Special Ed. Yes/No School Contact Other Household Members: Name Age D.O.B. Race/Hisp. Origin (use options listed above) School Relationship to patient Reason for Referral (box will expand on electronic format): Behaviors of Concern: Child Domain (topics might include presentation, behaviors, coping skills, cognitive abilities, etc): Child/Family Domain (topics might include relationships within the family, parenting styles, history, crises management): Child/School Domain(topics might include academic, behavioral, or social concerns): Child/Physical Environment/Systems Domain (topics might include important service providers involved with the family, community support available, other systems involvement like DCF/CSSD): What do you want IICAPS to work on with this child/family?:

3 Page 3 of 5 Diagnosis (Include Codes): Code Number: Description: Medical Condition(s): Psychosocial Stressors: Problems with primary support group Problems with social environment Problems with legal system Educational problems Occupational problems Housing problems Other: None GAF (Global Assessment of Functioning): Current Medications: Name Dose Frequency Past Medications: Name Dose Frequency Past Psychiatric Hx: (include information about psychiatric hospitalizations (place of admission, dates, reason for admission) as well as other forms of mental health treatment provided to child. Medical History (hospitalizations, medical conditions or concerns): Current Treaters: Family Member Receiving Service Institution/Agency Type of Service (individual therapy, inpatient, outpatient) Telephone # Name of Contact

4 Page 4 of 5 Past Treaters: Family Member Receiving Service Institution/Agency Type of Service (individual therapy, inpatient, outpatient) Telephone # Name of Contact IICAPS Coordinators are reminded to enter data into the IICAPS Web-based system (BMS) promptly. Any cases not accepted should document the reason for rejection and more appropriate programs within the Reason for Rejection box on the Main Episode of Care Screen.

Consent for Referral I have been informed by that my family (Referral Agency) has been referred to the Greater Danbury Intensive In-Home Child and Adolescent Psychiatric Service (IICAPS) of Family &

5 Consent for Referral I have been informed by that my family (Referral Agency) has been referred to the Greater Danbury Intensive In-Home Child and Adolescent Psychiatric Service (IICAPS) of Family & Children s Aid, Inc. 75 West St. Danbury, CT (IICAPS Agency) I understand that someone from IICAPS will contact me to confirm that my family is interested in receiving IICAPS services, and that services will begin as soon as an IICAPS team is available and makes their first visit to my home. Current contact information: Name of Child: Home telephone #: Work #: Cell phone #: Street address: Apt: Town: Zip: If no telephone: The best way to contact me is -- Signature(s): Date Date 2005 Yale Child Study Center All materials are copyrighted and intended for IICAPS program use only.

HCAHPS Survey SURVEY INSTRUCTIONS

HCAHPS Survey SURVEY INSTRUCTIONS You should only fill out this survey if you were the patient during the hospital stay named in the cover letter. Do not fill out this survey if you were not the patient.