Please use the following template to refer for Case Management services through the Division of Children’s
Behavioral Health Services. Download form to complete then fax to 877-736-9166. Referrals must be
completed by an independently licensed clinician (i.e. LCSW, LPC, MD, PsyD). All fields are mandatory and
must be typed.
Date:
Assessor Name:
Assessor’s Agency
Child’s Name:
Phone #:
DOB:
Permanent Address:
State:
Credentials:
CYBER ID#: (if known)
Gender:
Race/Ethnicity:
City:
Zip:
Parent/Legal Guardian
Consent for treatment contact person:
Address:
Primary Phone:
City:
State:
Zip:
Secondary Phone:
Current Living Situation:
Address if different from above:
Primary language spoken in the home
REASON FOR REFERRAL:
Current DSM-IV diagnoses: (all required)
Axis I
Axis II
Axis III
Axis IV
Axis V
Please note credentials/specialty of diagnosing provider (psychologist, psychiatrist etc) and date of evaluation:
Date
Current prescription medications: Specify all: (Name, dosage, frequency, start and end dates):
Any current or chronic physical health conditions:
Any current court orders? Yes
Specify:
No
Specify all:
Child Name:
Date:
Has he/she been diagnosed as having any of the following: (check all that apply)
Asperger’s Disorder
Mathematics Disorder
Pervasive Developmental
Disorder NOS
Expressive Language
Disorder
Phonological Disorder
Rett’s Disorder
Autistic Disorder
Communication Disorder NOS
Learning Disorder NOS
Mental Retardation
Mixed Receptive-Expressive Language
Disorder
Disorder of Written Expression
Reading Disorder (Dyslexia)
Stuttering
Other learning problems:
Childhood Disintegrative
Disorder
Developmental Coordination
Disorder
If yes to any of the above, provide Full Scale IQ and/or adaptive functioning scores
Any history of abuse or neglect?
YES
NO
Describe:
Current Legal Guardian Status (i.e. DYFS Custody or Guardianship)
Current Multi-System Involvement:
DYFS
Behavioral Health
DDD
Division of Family Development
Juvenille Justice
Special Education
DAS
Other
Contact information for DYFS and/ or DDD case worker and supervisors, if involved:
DYFS:
DDD:
CHILD BEHAVIORAL/EMOTIONAL NEEDS (please check any behaviors that are relevant to the treatment
needs of the child and/or exhibited in the last 30 days):
Psychosis
Impulse/Hyper
Depression
Anxiety
Oppositional
Adj. to Trauma
Anger Control
Substance Use
Other(e.g. .cruelty to animals, destruction of property etc.)
Detailed description of all checked behaviors/symptoms:
CHILD RISK BEHAVIORS (please check any issues that are relevant to the treatment needs of the child and/or
exhibited in the last 30 days):
Suicide Risk
Danger to Others
Runaway
Sexual Agression
Self-Mutilation
Judgement
Delinquency
Fire Setting
Other Self Harm
Social Behavior
Detailed description of all checked behaviors/symptoms:
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Child Name:
Date:
LIFE DOMAIN FUNCTIONING (please check any issues that are relevant to the treatment needs of the
child and/or exhibited in the last 30 days):
Family
Legal
Social
Development
Developmental
Vocational
School
Physical Needs
Relationship Permanence
Living
Situation
Medical
Needs
Recreation
Sexuality (i.e. sexual orientation and/or
sexual development)
Detailed description of all checked behaviors/symptoms:
Caregiver Name:
Caregiver Relationship to child:
CAREGIVER NEEDS (Check all that apply):
Physical Disability
Substance Use
Mental Health
Developmental Disability
Safety of Immediate Living Environment
Detailed description of all checked needs:
CAREGIVER STRENGTHS (Check all that apply):
Supervision
Service Coordination Abilities
Involvement
Community Supports
Residential Stability
Detailed description of all checked strengths:
*All referrants are legally required to report suspected child abuse or neglect to DYFS at
800-NJ ABUSE
CURRENT STATUS/INVOLVEMENT (check all that apply):
School
Regular
Child
Welfare/DYFS
Juvenile
Justice
Behavioral
Health
DDD
None
Special
Ed
Intake
Home
Instruction
In-Home
Services
Specialized
School
Resource/Foster
Home
None
Pending
FCIU
Probation
Day Program
None
DAP
Outpatient
Incarceration
Intensive InHome
Parole
Partial/Day
Hospital(Psych)
None
Intake
Day
Program
In-Home
Supports
Residential
3
Therapeutic
Treatment
Home
Detention
Out of
Home
Community
Supports
Child Name:
Date:
For any checked services, name facility/agency/provider and start date of service:
HISTORY (check all that apply): Limit to past 3 years.
School
Regular
Child
Welfare/DYFS
Juvenile
Justice
Behavioral
Health
DDD
None
Special
Ed
Intake
Home
Instruction
In-Home
Services
Specialized
School
Resource/Foster
Home
None
Pending
FCIU
Probation
Day Program
None
DAP
Outpatient
Incarceration
Intensive InHome
Parole
Partial/Day
Hospital(Psych)
None
Intake
Day
Program
In-Home
Supports
Therapeutic
Treatment
Home
Detention
Out of
Home
Community
Supports
Residential
For any checked, name facility/agency/provider and date of service (start and end):
Information Sources (e.g. Parents, Foster Parents, Group Home Worker, Probation Officer, teacher etc.):
(Include name, relationship to the child, phone number)
Clinical Formulation:
Signature of Assessor: __________________________________________(required) Date: _______________
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