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Details of this error have been logged.Submission Success!Patient DemographicsPatient First Name*Patient Middle NamePatient Last Name*PronounsPreferred NameDate of BirthAge*Home Address*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOther5-Digit Zip-Code*Gender*MaleFemaleNon-Binary (Please Specify)Please Specify (If Non-Binary)Legal Guardian InformationGuardian First Name*Guardian Middle NameGuardian Last Name*Relationship to the patient being referred*Guardian Address*Guardian City*Guardian State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherGuardian Zip*Guardian Phone Number*Guardian EmailPatient Background InformationIs the patient being referred currently in treatment?*YesNoIf yes, please indicate treatment providerIf yes, type of treatment services currently providedPlease describe current behaviorsDoes the patient being referred have a history of running away?*YesNoPlease describeDoes the patient being referred have a history of suicide attempts or ideation?*YesNoPlease describeDoes the patient being referred have a history of fire setting?*YesNoPlease describeDoes the patient being referred have a history of sexually inappropriate behavior*YesNoPlease describeDoes the patient being referred have a history of substance abuse?*YesNoPlease describe the substance used, last use and frequency of useHas the patient being referred experienced any major traumatic events or changes in his or her life (ie physical, sexual or emotional abuse, rape, significant illness, grief/loss)YesNoPlease describeType of treatment requested*Please SelectAlcohol & Drug Residential TreatmentIntermediate Care FacilityMental Health Residential TreatmentTherapeutic Group HomePatient HeightPatient WeightAny current or past involvement in the legal system?*YesNoIf no, please skip next sectionLegal IssuesPlease describe the reasons and charges receivedProbation Officer NameProbation Officer NumberProbation Officer EmailDoes the patient have a juvenile court officer, probation officer, or court involvement?*YesNoPlease describeCurrent Psychiatric DiagnosisPsychiatric DiagnosesFull Scale IQDoes the patient have an Autism Spectrum Disorder (ASD) diagnosis?*YesNoPlease describeMedical DiagnosesAsthmaDiabetes Type 1Diabetes Type 2Cardiac IssuesTraumatic Brain InjurySexually Transmitted Infections/DiseasesSeizuresGastrointestinal DiseaseOther (Please Describe)Please describeAre there any health problems, allergies or physical limitations?*YesNoPlease describePrevious TreatmentHas the patient had any of the following (check all that apply)Outpatient therapy (via therapist, counselor, or social worker)Psychological Testing (via psychologist or neuro-psychologist)Medication managementFamily therapyInpatient hospitalizationPartial hospitalization program (PHP)Intensive outpatient program (IOP)Residential Treatment (PRTF/RTC)Therapeutic Group Home (TGH)Wrap-around in-home servicesOther (please describe)If other, please describePlease list any providers and city, state for the above servicesEducational InformationEnrolled in school?*Yes, currently enrolledNo, not enrolledSchool AttendingCurrent GradeHighest grade completedPlease describePlease describe how the child does in school (include any difficulties in school)Does the patient have an IEP, 504B, or other?*YesNoPlease upload IEP/504B/OtherCombined total of all files may not exceed 7MB.Primary Healthcare InformationInsurance Company*Insurance Policy NumberGroup NumberPolicy Holder NameCustomer/Member Service PhoneMental/Behavioral Health Benefits PhoneSubscriber DOBSubscriber EmployerSubscriber AddressSubscriber PhoneSecondary Healthcare InformationInsurance CompanyInsurance Policy NumberGroup NumberPolicy Holder NameCustomer/Member Service PhoneMental/Behavioral Health Benefits PhoneReferral DocumentationIf you have any referral documentation to upload, please attach it belowCombined total of all files may not exceed 7MB.RemoveAdd Another (6 remaining)How Did You Hear About UsName of person who referred youAgency they are associated withHave you been working with a Treatment Placement Specialist or Resource Coordinator with Children's Behavioral Solutions?*YesNoIf yes, who?Name of person completing this formYour First Name*Your Middle NameYour Last Name*Relationship to the patient being referred*Referrer Address*Referrer City*Referrer State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherReferrer Zip*Referrer Phone*Referrer EmailName of person who referred you*Agency they are associated with*Reason for referral*Same as Legal Guardian?YesNoOrganizationTerms and ConditionsBy submitting this referral form, you are giving permission for Acadia to research various treatment options for the patient you are referring. The information is completely confidential and a resource coordinator will be in contact with you shortly after reviewing the information suggesting the best treatment options.Terms and Conditions Accepted*I accept
