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

Child's Race

Child's Ethnicity

Referred By

Agency (If Applicable)

Referrer's Contact Number

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Referrer's Contact Email

Medical Assistance Number

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

Guardian 1 Alt. Phone

Primary language of guardian, if not English

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

Person With Medical Rights

Person With Custody

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

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

Describe any current mental health diagnoses the child has.

Tell us all medications the child is currently taking.

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

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

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Outpatient Facilities

Inpatient Facilities

CRISIS Centers

Residential Treatment Facilities

Family Based Mental Health Services

Mental Health- Intellectual and Development Disabilities

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

Child's Current School

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

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Child's Grade Level

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

Please list any other agencies you have referred to for similar services.

Is there anything else we should know about the child?

BRIDGES™ Referral Form

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