Psychiatric Rehabilitation Youth Referral Form

If the required field is unknown, please enter 'N/A' or 'Not Applicable.

Name of persom making the referral*

Email of person making referral*

Client Information

Date of Birth:*

Gender

SSN:

Race:*

Client Phone:*

Client Email

Current Grade Level or Highest Grade Completed:*

Current School Name:

Legal Guardian Phone*

Legal Guardian Email

Relationship to Client*

Name of Peer Support Provider and preferred contact:*

Name of Target Case Management Provider and preferred contact:*

Name of IOP Provider and preferred contact:*

Name of Partnering Agency and preferred contact:*

Current Mental Health Information

Treating Therapist Credentials

Supervising Therapist Credentials

Solo/Group/OMHC Therapy Provider Agency Name*

Solo/Group/OMHC Therapy Phone:

Solo/Group/OMHC Therapy Provider Email

Please upload evidence of the Clinical Diagnosis that supports this request for Youth CSS/Psych Rehab Services*

Upload Clinical Diagnosis Evidence Here

Drop files here or

Max. file size: 32 MB.

As the Supervising or Treating Therapist, I authorize WIN Team CSS (Psych Rehab Services) to receive, collect and verify the information provided on this form for screening purposes, to confirm the eligibility and appropriateness of services available, and initiate WIN community behavioral health services to the above-referenced youth.*

Credentials

Referral Date*

If you have a signed release of information, please upload it. There is a link to WIN's release on referral info page

Max. file size: 32 MB.

Name

This field is for validation purposes and should be left unchanged.

Psychiatric Rehabilitation Youth Referral Form

Psychiatric Rehab Youth Referral Form

If the required field is unknown, please enter 'N/A' or 'Not Applicable.

Client Information

Current Mental Health Information