Referral Form

To better protect and heal children from trauma and its emotional impact

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Home
About
- Our Team
- How We HELP
What We Do
Parents & Caregivers
- Family Stories
- How to Find a Therapist
Training
NCHP
Research
- Current Studies & Projects
Calendar of Events
News
- Presentations
- Publications
Contact
- Referral Form
How To Help

To better protect and heal children from trauma
and its emotional impact

Home
About
- Our Team
- How We HELP
What We Do
Parents & Caregivers
- Family Stories
- How to Find a Therapist
Training
NCHP
Research
- Current Studies & Projects
Calendar of Events
News
- Presentations
- Publications
Contact
- Referral Form
How To Help

Home
About
- Our Team
- How We HELP
What We Do
Parents & Caregivers
- Family Stories
- How to Find a Therapist
Training
NCHP
Research
- Current Studies & Projects
Calendar of Events
News
- Presentations
- Publications
Contact
- Referral Form
How To Help

Home

Contact

Referral Form

This is our Referral Form. If you would like to use our General Contact Form, please click here.

Referral Form For Child HELP Partnership Therapy

Child Demographics:

Child Name

Today's Date (DD-MM-YYYY)

Date of Birth (DD-MM-YYYY)

Age

Gender

Girl Boy Non-Binary Other

Child's Race/ethnicity (check all that apply)

Caucasian African American/Black Latino/Hispanic South Asian East Asian Middle Eastern/North African Other

Fluent in English

Yes No

Able to Attend in Person

Yes No

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

Caregiver Demographics:

Name of primary caregiver (has custody & at least 50% decision making capacity):

Relationship to child

Phone

Caregiver’s address:

Caregiver’s race/ethnicity (check all that apply):

Caucasian African American/Black Latino/Hispanic South Asian East Asian Middle Eastern/North African Other

Fluent in English:

Yes No

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

Reason for Referral:

Which of the following has happened to the child you are referring?

1. A bad accident, like a car crash or a bike accident

Yes No Don't know

2. A disaster, like a fire, hurricane, or tornado:

Yes No Don't know

3. Having someone hurt them or them seeing someone else get hurt (e.g., physical/sexual abuse, witnessing DV):

Yes No Don't know

4. Having someone important (parent sibling, friend) die:

Yes No Don't know

5. Being treated badly because of race, ethnicity, or religion:

Yes No Don't know

6. A serious medical procedure:

Yes No Don't know

7. Other Yes / No:

Yes No Don't know

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

Why are you referring this child for trauma therapy? Specifically, what emotional and/or behavioral problems have you observed?

Please check all that apply:

Not attending school:

Yes No Don't know

Legal involvement (e.g., active custody dispute):

Yes No Don't know

Suspected eating disorder (e.g., anorexia, bulimia):

Yes No Don't know

Self-harming behavior and/or suicidal/homicidal ideation:

Yes No Don't know

Lack of expressive language/autism spectrum disorder:

Yes No Don't know

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

Treatment History. Please check all that apply:

Inpatient/residential psychiatric care

Yes No Don't know

Day treatment/partial hospitalization/intensive outpatient program

Yes No Don't know

Outpatient therapy

Yes No Don't know

Emergency room visits for mental health concerns

Yes No Don't know

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

If you are a professional working with the family (vs. a parent), please complete the following:

Name of professional:

Phone

Name of professional’s organization:

If maltreatment, was it investigated by ACS?

Yes No Don't know

If investigated, was the maltreatment substantiated?

Yes No Don't know

Name of ACS Worker (if other than professional making the referral)

Phone

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

Any additional notes:

Please provide any additional information here:

Referral Form For Child HELP Partnership Therapy

Child Demographics:

Child Name

Today's Date (DD-MM-YYYY)

Date of Birth (DD-MM-YYYY)

Age

Gender

Girl Boy Non-Binary Other

If child gender other please enter it here:

Child's Race/ethnicity (check all that apply)

Caucasian African American/Black Latino/Hispanic South Asian East Asian Middle Eastern/North African Other

If child race other please enter it here:

Primary Language Spoken by the child

Fluent in English

YES NO

Able to Attend in Person

YES NO

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

Caregiver Demographics:

Name of primary caregiver (has custody & at least 50% decision making capacity):

Relationship to child

Phone

Caregiver’s address:

Caregiver’s race/ethnicity (check all that apply):

Caucasian African American/Black Latino/Hispanic South Asian East Asian Middle Eastern/North African Other

If caregiver race other please enter it here:

Fluent in English:

YES NO

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

Reason for Referral:

Which of the following has happened to the child you are referring?

1. A bad accident, like a car crash or a bike accident

Yes No Don't know

2. A disaster, like a fire, hurricane, or tornado:

Yes No Don't know

3. Having someone hurt them or them seeing someone else get hurt (e.g., physical/sexual abuse, witnessing DV):

Yes No Don't know

4. Having someone important (parent sibling, friend) die:

Yes No Don't know

5. Being treated badly because of race, ethnicity, or religion:

Yes No Don't know

6. A serious medical procedure:

Yes No Don't know

7. Other Yes / NO:

Yes No

If other - Please Specify:

Why are you referring this child for trauma therapy? Specifically, what emotional and/or behavioral problems have you observed?

-------------------------------------------------------------------------------------------------------------------------------------------------------------------

Please check all that apply:

Not attending school:

Yes No Don't know

Legal involvement (e.g., active custody dispute):

Yes No Don't know

Suspected eating disorder (e.g., anorexia, bulimia):

Yes No Don't know

Self harming behavior and/or suicidal/homicidal ideation:

Yes No Don't know

Lack of expressive language/autism spectrum disorder:

Yes No Don't know

Other Yes / NO:

Yes No

If other - Please Specify:

-------------------------------------------------------------------------------------------------------------------------------------------------------------------