Referral Form - Children's Care Coordination 2026

1. Click ‘Get Form’ to open the Referral Form - Children's Care Coordination in the editor.
2. Begin by entering the 'Date of Referral' at the top of the form. This is essential for tracking purposes.
3. Fill in the 'Demographic Information' section, including the youth's name, address, phone numbers, gender, date of birth, and Medicaid number.
4. Complete the 'Parent/Legal Guardian(s)' section. If applicable, ensure to attach any required court orders.
5. Indicate ethnicity, race, language preferences, and any special accommodations needed in the designated checkboxes.
6. Provide details about the youth's living situation and current school information. Include any special education services if applicable.
7. In the 'Behavioral Health Diagnosis' section, list any diagnoses and medications along with their ICD codes.
8. Finally, review and sign the 'Release of Information' section before submitting your completed form for processing.

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