Washington County Human Services Department
Child Services Referral Form
333 E. Washington Street, Suite 2100, West Bend WI 53095 (262) 335-4583
Comprehensive Community Services deanna.depies@co.washington.wi.us
School Based Services eric.diamond@co.washington.wi.us
Coordinated Services Team eric.diamond@co.washington.wi.us
Strengthening Families alicia.leslie@co.washington.wi.us
Lifespan Outpatient jaclyn.moglowsky@co.washington.wi.us
Lifespan In-home jaclyn.moglowsky@co.washington.wi.us
Adolescent IOP eric.diamond@co.washington.wi.us
Person making Referral
EXT
Role w/ client
Date of Referral
Name of Child
(First)
(Middle)
(Last)
Date of
Birth
Age
T-19/ MA Number
Other Insurance
Reason for Referral
Parent(s) /Guardian(s) Name(s)
(First)
(First)
(Middle)
(Middle)
(Last)
(Last)
Child Lives With
((Name)
(Relationship)
At
(Complete Address)
Current School
(School Name)
School
Contact
Information
(Address, Telephone, Contact Person email)
IEP (Yes or
No)
(School Contact Person)
Referring Party should discuss with the parent/guardian and child the program to which they will
be referred and the purpose of the referral. Please identify the parent/guardian’s and child’s
response to your discussion with them about the referral.
TELEPHONE NUMBERS
Home of Child
In Emergency
Mother
Work
Cell
Father
Work
Cell
Members of Household
(List all persons living in the home with the child)
Full Name
Age
Relationship to Child
List all other Family Members /Significant Others who are involved with the child or family
(Aunt, Uncle, Big Brother/Sister, Mentor, Grandparent)
Full Name
Age
Current Mental Health Diagnosis (Include who made the diagnosis and the date)
List all current medications, dosage , & prescribing Physician:
2
Relationship to Child
List of Current and Past Services or Interventions provided to child (Hospitalizations, Crisis Services, Outpatient
Services, Past and Present Court Orders, CPS reports, Past and Present Court Ordered Placements)
Intervention Name and Provider
Date(s)
Areas of Concern
Verbally assaultive (swearing
at /threatening adults)
Physically aggressive / has
harmed or attempted to harm
others
History of suicidal attempts
Self mutilating behavior/
cutting
Argumentative
Disrespectful
Threatens to harm peers/
others
Interpersonal problemsfrequent verbal conflicts with
peers /negative peer group
Self harm gesturing (i.e.
scratches self superficially)
Medical/ Developmental issues
impacting mental health
Threatens to harm self/ suicidal
statements
Mental Health diagnosis:
__________________
Past History of psychiatric
hospitalization/ alternative
placement
Odd/unusual behaviors/ Bizarre
vocalizations
Frequent mood swings (that
are not developmentally
typical)
Sexual acting out behavior
Enuresis/encopresis
Poor social skills (making
friends, interacting)
Auditory/visual hallucinations
Risk behavior (Alcohol/ Drugs,
gang, older peers)/ Criminal
behavior
Low Self-esteem/Motivation
Lethargy
Delusional thinking / Paranoia
Victim of violence/witness to
violence
Family issues
Damaged property in an
angry/ emotional episode
Has experienced a loss
(death/divorce/alienation)
Frequent Somatic Complaints
Recent loss of a parent /
primary caregiver
Non-compliance with
classroom/ school rules
Lack of self-responsibility/
accepting consequences
Blatant, intentional and
persistent oppositional
behavior in all settings
Victim of abuse/ neglect;
Exposure to significant
traumatic experience
Hoarding/Stealing food
Anxiety /Perfectionism
/Perseveration
Other:
Other:
3
Family Background
(Give brief history of the family, describe family dynamics, family roles and behaviors of the child)
Education/School Background
(Give brief history of academic ability, attendance, special education classes, both positive and
negative behaviors)
Community /Social Background
List the Strengths of the Child
(Give a brief history of how the child does in community and social settings or activities)
(Good with animals, creative, likes to read, can express needs, supportive family, etc.)
List the Strengths of the Family (Willing to learn new approaches, patient with child, organized, clean home)
What are the Goals /Outcomes you and the family anticipate achieving as a result of this referral?
4