Coordinated Services Team Initiative (Cst) (Page 2 of 7) in pdf

Coordinated Services Team Initiative (Cst) Page 2

Service Provider Information

Does the child have a Mental Health diagnosis?

If yes, please complete the remainder of the referral form, including the Severe Emotional

Disturbance (SED) Checklist (Appendix A).

If no, please complete the remainder of the referral form, and disregard the Severe Emotional

Disturbance (SED) Checklist (Appendix A).

Mental Health Provider: ________________________________________________

Contact Person: ________________________ Phone Number: _______________

Describe Involvement: _________________________________________________

_____________________________________________________________________

Is the child involved with the Juvenile Justice system,

Child Protective Services (CPS), or Alcohol/Other Drug Abuse (AODA)services?

If yes, please complete the provider information below and attach documentation of services

(can obtain through the family’s social worker).

If no, please continue with “Educational Provider” information.

Juvenile Justice, CPS, or AODA Service Provider:__________________________

Contact Person: ________________________ Phone Number: ________________

Describe Involvement: _________________________________________________

_____________________________________________________________________

Educational Provider:__________________ Special Education?

Yes

Contact Person: _______________________ Phone Number: ________________

Describe Involvement: _________________________________________________

_____________________________________________________________________

Other Agency/Provider:__________________ Phone Number: ________________

Contact Person: ________________________

Describe Involvement: _________________________________________________

_____________________________________________________________________

Module 2

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Coordinated Services Team Initiative (Cst) Page 2