The Children's Home of York : What We Do : BRIDGES™ Referral Form

Child's Full Name

First Name *

Last Name *

Child's Gender Identity

Male
Female
Non-binary
Other gender identity

Child's Date of Birth (Required)

Child's Race

Child's Ethnicity

Referred By (Required)

Agency (If Applicable)

Referrer's Contact Number (Required)

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Referrer's Contact Email (Required)

Medical Assistance Number (Required)

Guardian 1 Name

First Name *

Last Name *

Guardian 1 Address

Country

Address Line 1 *

Address Line 2

City *

State/Province *

Postal Code *

Guardian 1 Phone (Required)

Guardian 1 Alt. Phone

Guardian 2 Name

First Name

Last Name

Guardian 2 Address

Country

Address Line 1

Address Line 2

City

State/Province

Postal Code

Guardian 2 Phone

Guardian 2 Alt. Phone

Person With Educational Rights (Required)

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Person With Medical Rights (Required)

Person With Custody (Required)

Describe the child's current living situation. Foster care, residential treatment facility, living with biological parents, etc. (Required)

Describe why the child is currently seeking treatment in a Partial Hospitalization Program. (Required)

Describe any current mental health diagnoses the child has. (Required)

Tell us all medications the child is currently taking. (Required)

Describe any medical needs, limitations, or allergies our team should know about. (Required)

Has the child been involved with Children and Youth Services?

Yes
No

If yes, please explain

Has the child been involved with the Juvenile Justice System?

Yes
No

If yes, please explain

Outpatient Facilities (Required)

Inpatient Facilities (Required)

CRISIS Centers (Required)

Residential Treatment Facilities (Required)

Family Based Mental Health Services (Required)

Mental Health- Intellectual and Development Disabilities (Required)

Does the child have a history of:

Physical aggression
Sexual offenses
Fire setting
Suicide/self-harm
Elopement from placement/running away from home?
None of the above

If you answered, "yes," to any of the above, please explain.

Child's Current School District (Required)

Child's Current School (Required)

Is the child currently in alternative education or cyber school?

Yes
No

If yes, please explain.

School Contact Name

First Name *

Last Name *

School Contact Phone (Required)

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Child's Grade Level (Required)

Describe any special education needs the child has.

Does the child have an Individualized Education Plan/504 Plan?

Yes
No

If so, is the IEP/504 Plan for:

Emotional Support
Learning Support

Is there anything else we should know about the child?

What We Do

What We Do

BRIDGES™ Referral Form

Child's Basic Information

Insurance Information

Parent/Guardian Information

Guardian's Rights

Child's Background

Child's Treatment History (Type N/A if Child has no history)

Risk Management Assessment

School Information