WinGeorgia/LMCME IC3 Referral Form

WinGeorgia /Care Management Entity Intensive Customized Care Coordination High Fidelity Wraparound (IC3) Referral

Complete all required questions and click "Submit" to send a referral to WinGeorgia
Youth Information

All fields are required
Youth Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age*
Referral Date

MonthDayYear
Date
Birth Gender

FemaleMale
Gender Identify

Identifies as MaleIdentifies as FemaleFemale-to-Male (FTM)/Transgender Male/Trans ManMale-to-Female (MTF)/Transgender Female/Trans WomanGendergueer, neither exclusively male nor femaleChoose not to discloseAdditional gender category or other, please specify
Race*

American Indian/Alaskan NativeAsian-OtherBlack/African-AmericanLatino-HispanicLatino-Non-HispanicPacific IslanderMultiracialWhite/CaucasianOther Single RaceUnknown/Not Indicated
Primary Language Youth/Parents

EnglishSpanishFrenchGermanMandarinPortugueseTagalogItalianPolishNot Specified/Unknown
Insurance Information
Youth's Insurance Carrier
Youth's Insurance Policy Number*
Placement Information
Is child in DFCS Custody?*

YesNo
Parent/Guardian's Name*

First NameLast Name
Foster Parent Name*

First NameLast Name
Phone Number
Address*

Street Address

Street Address Line 2

CityState

Zip Code
County of Residence*
DFCS Information
DFCS Primary Contact

First NameLast Name
DFCS Case Worker Primary Phone #
DFCS Primary Contact Email
example@example.com
DFCS Case Worker Supervisor Name

First NameLast Name
DFCS Supervisor Primary Phone #
DFCS Supervisor Primary Contact Email
example@example.com
DFCS Agency County
DFCS Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Family Contact Information
Family Contact Name*

First NameLast Name
Contact info is that of:*

ParentGuardian
Family Phone # *
Other Phone #
Family Email
example@example.com
Would you like to add an additional contact?*

YesNo
Additional Contact info is that of:

ParentGuardian
Additional Contact Name

First NameLast Name
Phone #
Referral Source
Select source of Referral*

Parent/GuardianInpatient HospitalResidential Facility (PRTF)DJJ In CommunityDJJ Secure FacilityDBHDD Core ProviderPrivate Provider or PediatricianJuvenile CourtDFCS Family PreservationDFCS Custody (GA Families 360)System of Care (LIPT/CHINS/CSEC)School SystemCrisis Stabilization Unit (CSU)Family Support Organization
Name of Referring Individual*

First NameLast Name
Referring Agency*
Referrer Phone #*
Referrer Email*
example@example.com
DJJ Information
Is youth under supervision with DJJ or staying in a DJJ facility?

YesNo
DJJ Contact Person
DJJ Juvenile ID
If DJJ secure facility, name of facility
Date of release (if in secure facility)

MonthDayYear
Date
Youth's # of placement changes in the past year
Amerigroup Georgia Families 360 Info

For DJJ/DFCS or Adoption Assistance Parents use only
Amerigroup Care Coordinator (ACC)

First NameLast Name
ACC Phone #
ACC Email
example@example.com
Other Agencies Currently Involved
Select Agencies Currently Involved

Enrolled in School (check if YES)Inpatient HospitalPRTF (Residential Facility)Child Caring Inst. (Group Home)Dept. of Juvenile JusticeDBHDD Core ProviderPrivate Provider or PediatricianJuvenile CourtDFCS (non-custody only)DFCS Custody (GA Families 360)Family Support OrganizationLaw EnforcementCrisis Stabilization UnitGeorgia Cares (CSEC)
Name of Inpatient Hospital
Name of PRTF
Name of Child Caring Inst./Group Home
Name of Private Provider/Pediatrician
Name of Crisis Stabilization Unit
Behavioral Health Information
Agency Name:
Contact Name:

First NameLast Name
Contact Phone Number:

Area CodePhone Number
Contact Email:
example@example.com
Mental Health Diagnosis (Most Prevalent):*
Diagnosed by
Effective Date of Diagnosis

MonthDayYear
Clinic/Agency
Mental Health Diagnosis (Secondary):
Diagnosed by
Effective Date of Diagnosis

MonthDayYear
Clinic/Agency
Substance Abuse Diagnosis:
Diagnosed by
Effective Date of Diagnosis

MonthDayYear
Clinic/Agency
Medical Diagnosis:
Diagnosed by
Effective Date of Diagnosis

MonthDayYear
Clinic/Agency
Does youth currently take prescribed medications?

YesNoUnknown
Medication(s)
CANS?*

YesNo
If Yes to CANS, please attach copy of most recent CANS

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Current Clinical Information: Anxiety Disorders*

	Mild	Moderate	Severe	Acute	Chronic	N/A
Obsession/Compulsion
Generalized Anxiety
Panic Attacks
Phobias
Somatic Complaints
PTSD Symptoms

Current Clinical Information: Mania*

	Mild	Moderate	Severe	Acute	Chronic	N/A
Insomnia
Grandiosity
Pressured Speech
Racing Thoughts / Flight of Ideas
Poor Judgement / Impulsiveness

Current Clinical Information: Psychotic Disorders*

	Mild	Moderate	Severe	Acute	Chronic	N/A
Delusions / Paranoia
Self-Care Issues
Hallucinations
Disorganized Thought Process
Loose Associations

Current Clinical Information: Depression*

	Mild	Moderate	Severe	Acute	Chronic	N/A
Impaired Concentration
Impaired Memory
Psychomotor Retardation
Sexual Issues
Appetite Disturbance
Irritability
Agitation
Sleep Disturbance
Hopelessness / Helplessness

Current Clinical Information: Substance Abuse*

	Mild	Moderate	Severe	Acute	Chronic	N/A
Loss of Control of Dosage
Amnesic Episodes
Legal Problems
Alcohol Abuse
Opiate Abuse
Prescription Medication Abuse
Polysubstance Abuse

Other Substance Abuse

Current Clinical Information: Personality Disorder*

	Mild	Moderate	Severe	Acute	Chronic	N/A
Oddness / Eccentricities
Oppositional
Disregard for Law
Recurring Self Injuries
Sense of Entitlement
Passive Aggressive
Dependency

Other Personality Disorder (Enduring Traits of)
Response to current treatment:*

Presenting Problems (Include Historical)*

	Select all that apply
Self-Harm
Sexual Offense
Fire setting and / or property destruction
Runaway
Threats of Violence
Active Substance Use
Behavioral problems
Imminent risk of out-of-home placement

Please provide details for any Presenting Problems listed above occurring within the last 180 days (six months)*
Youth and Family History*
Is the youth able to meet basic needs, fulfill usual role maintain health & wellness?*

YesNo (if no, please explain below)
Strengths
What are the youth’s strengths?
What are the family’s strengths?
What are the current stressors in the home environment?*
Stressors could be home, school, work... that interferes with well-being of youth.
Natural Supports Involved?*

YesNo
Services

Services Received*

	Select	Where	AdmissionDate mm/yyyy	DischargeDate mm/yyyy	#of admits
Inpatient Hospital
Residential Treatment Facility
Child Caring Institute (CCI)
DJJ
DFCS
Juvenile Court
Regional Youth Detention Center
Youth Development Center
Crisis Stabilization Unit
Other

# of Inpatient Admissions
Please list dates of Inpatient Hospital admissions/discharges starting with most recent. Click + button to add additional dates.
# of PRTF Admissions
Please list dates of Residential Treatment Facility admissions/discharges starting with most recent. Click + button to add additional dates.
# of CSU admissions
Please list dates of Crisis Stabilization Unit admissions/discharges starting with most recent. Click + button to add additional dates.
# of RYDC Stays
Please list dates of Regional Youth Detention Center admissions/discharges starting with most recent. Click + button to add additional dates.
Local Interagency Planning Team (LIPT)
Has youth/family been presented at LIPT?

YesNo
LIPT Recommendation:
Was a WinGeorgia staff present when presented at LIPT? If yes, please provide staff name.
Children in Need of Services (CHINS)
Has youth/family been presented at CHINS?

YesNo
CHINS Recommendation:
Needs

(i.e. homelessness, teen pregnancy/parent, legal issues, problems in school, etc.)
Please describe difficulties youth is facing
Informed Consent
*** REMINDER ***

If a youth is 18 to 20 years old they will need to accept Wraparound unless under custody of DFCS or DJJ.
Has the parent/guardian been informed about services provided by WinGeorgia CME and provided consent for this referral to be placed?*

YesNo (Please explain below)
Is the parent accepting of support from Wraparound?*

YesNo
WinGeorgia CME
How did you hear about WinGeorgia CME?

WinGeorgia Staff (please specify name below)WebsiteCommunity Meeting (please specify meeting and county below)
Staff Name/ Meeting-County
Do you have the following information: Diagnosis verification, Behavioral Health Assessment, CSU/PRTF discharge papers, Psychological, DR. Apt note, CANS, and copy of Insurance cards?

YesNo
If yes, please upload supporting documentation

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Should be Empty:

	No Concern	Some Concern	Needs Attention
Psychosis
Attention/Concentration
Impulsivity
Depression
Anxiety
Substance Abuse
Attachment Difficulties
Anger Control
PTSD
Phobias
Obsession/Compulsion

	No exposure	Past exposure causing some difficulties now	Currently exposed or experience moderate to extreme difficulties as result
Sexual Abuse
Physical Abuse
Emotional Abuse
Neglect
Witness to Family Violence
Community Violence
School Violence
Disruptions in Caregiving/Attachment Losses

	No difficulties	Some difficulties	Moderate-Extreme difficulties
Family
Living Situation
Social Functioning
Legal
Sleep
Recreational
School Behavior

WinGeorgia /Care Management Entity Intensive Customized Care Coordination High Fidelity Wraparound (IC3) Referral

Youth Information

Insurance Information

Placement Information

DFCS Information

Family Contact Information

Referral Source

DJJ Information

Amerigroup Georgia Families 360 Info

Other Agencies Currently Involved

Behavioral Health Information

Strengths

Services

Local Interagency Planning Team (LIPT)

Children in Need of Services (CHINS)

Needs

Informed Consent

WinGeorgia CME