CPS / Belong Referral for Psychiatric Evaluation
This referral application is only for caseworkers of clients with CPS or Belong.
Case Details
Which organization are you with?
*
Texas Dept. of Family and Protective Services (DFPS)
Belong (SJRC Texas)
Other
What is the location (city) of your DFPS office?
*
If the CPS provider is other than DFPS, enter the city in which the CPS case is being serviced.
Which CPS department are you with? (or CPS equivalent)
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Investigations
Family-Based Safety Services
Conservatorship
Adoptions
Legal
Other
Please upload Form 2054 (CPS Service Authorization)
*
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Form 2054 should be completed for code 86B, one unit. A 2054 is required for all referrals, even if the client is a minor as we do not bill Medicaid.
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What is the Service Authorization End Date (from Form 2054)
*
-
Month
-
Day
Year
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Is there a court affidavit for this case?
*
Yes
No
Court affidavit
*
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Note: Information in the court affidavit which is duplicated in Form 2036 may be excluded in Form 2036.
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Please upload Form 2036 (Referral for Evaluation & Treatment and Battering Intervention and Prevention Program Services)
*
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Note: If a court affidavit is provided, Information in the court affidavit which is duplicated in Form 2036 may be excluded in Form 2036. If a court affidavit is not provided, please address each section of the 2036.
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Has the client had a previous psychological evaluation?
*
Yes
No
Previous psychological evaluation report
*
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Caseworker Contact Info
Caseworker Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Caseworker Primary Phone
*
Please enter a valid phone number.
Caseworker Alternate Phone
Please enter a valid phone number.
Caseworker Primary Email
*
example@example.com
Caseworker Alternate Email
example@example.com
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Client Contact Info
Client Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Client Demographic
*
Adult
Child
Caretaker Name for Client
*
Prefix
First Name
Middle Name
Last Name
Suffix
Caretaker's Relationship to Client
Client's Primary Phone
*
Please enter a valid phone number.
Primary Phone Label
Alternate Phone 1
Please enter a valid phone number.
Alternate Phone 1 Label
Alternate Phone 2
Please enter a valid phone number.
Alternate Phone 2 Label
Client's Primary Email
example@example.com
Primary Email Label
Alternate Email
example@example.com
Alternate Email Label
Sender Email
example@example.com
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