http://www.peoplequestedi.org/SIERRA REGIONAL CENTER

Psychological Services Referral

 

Please provide comprehensive information that is specific.   This page should be filled out completely.  

Date of Referral:       Provide minutes from most recent team meeting (APC or other).

Person being referred:                      Case #:                    D.O.B.:      

Person submitting referral:                Phone #:      

Contact person (if different from above):                    Phone #:      

 

Reason for referralReason for referral

 

 

 

 

 

 
     Check here if a formal evaluation is needed (e.g., for CTC eligibility, medicaid requirements, etc.) Previous assessment results:

 

Test:_________________________ Results: __________________________ Date given:_________ 

 

 

 

 

 

 

 

 

 

 

 

 
     Check here if the referral concerns a behavioral issue (e.g., behavioral assessment, intervention, counseling, etc.). For behavioral issues, state the presenting problem in the space provided below and complete both sides of the attached “Behavioral Supplement to Psychological Services Referral”.

 

Presenting problem:       

Matter of Urgency:Matter of Urgency     

Urgent: Requires immediate attention due to a potential for harm to self or others; and/or an increase in the identified problem.

Normal: This problem needs to be addressed as appropriate.

Future: This matter needs to be addressed within the next 2-3 months.

 

Treatment Concerns:

Is the person being referred willing to receive services?  Yes   No

Is the person being referred willing to receive services? __________________________________________What is currently being done to address the presenting issue:       What is currently being done to address the presenting issue:  ______________________________________

_______________________________________________________________________________________

 

 
Clinical Services Response:  Assigned to: _________________________________ Date: _________

Response/action:

____ Review of Problem/issue                                                          ____ Family/Child therapy

____ Behavior Assessment and recommendations                       ____ Psychological Evaluation

____ Behavior assessment and intervention                                  ____ Group Therapy/Training, Type(s):______________________

____ Parent Training                                                                          ____ Individual Counseling

 

Specific Action to be taken next: ___________________________________________________________

Service Review Date:  ______________________

 

Signature: ________________________________________          Date of response: __________________

SIERRA REGIONAL CENTER

Behavioral Supplement to Psychological Services Referral

This information is intended to provide a starting point for assessing the behavior problem for which you have requested consultation.  Please provide information to assist us in determining how to best address your referral concern.

Client Name:       

Current Status:      

PC/Case Manager:      

Home Manager:      

Residential Placement:      

School Placement (school and teacher):      

Vocational Placement (agency and supervisor):      

Medical Conditions/Medications:      

Psychological/psychiatric treatment and Diagnoses:      

Other supports:      

Identify Recent Changes in the Person=s LifeIdentify Recent Changes in the Person=s Life:

Environment: (e.g., staff; teacher; family; peers; supervisor; living, vocational, or school placements; new routines; physical environment; etc.)       

Prescribed Medications:      

Medical condition:      

Psychological/Psychiatric Condition:

Summary of Behaviors: For each of the categories below, provide concrete/specific descriptions of behavior.

 

Target behaviors

 

 

Problem Behavior to Decrease

 

Alternative Behavior to Increase

 

     

 

     

 

     

 

     

 

     

 

     

 

     

 

     

 

Behavioral Supplement to Psychological Services Referral  


What is the effect on staff and peers?        Who are these behaviors a problem for?         Who is affected the most?

Do other behaviors usually precede any of the behaviors listed above?  (List by identified behavior):      

Are there certain people, activities, and/or stimuli that seem to trigger any of the behaviors?      

 

Are there certain times of day or specific environments in which any of the behaviors tend to occur?      

 

What happens as a result of the listed behaviors (e.g., property damage, harm to others, etc.)?       

 

Why do you think the person engages in the listed behaviors?  (i.e., Does the person appear to get something by engaging in the behaviors)?  For example: attention, preferred items, or escape from demands?)       

 

Why are each of the listed behaviors a problem? (e.g., interferes with daily activities, risk of loss of placement, interferes with learning, interfere with integration in the community, etc.)      

What will happen if the listed behaviors continue?      

What is the expected outcome of this behavioral consultation: