Houston Child Referral Form Child & Adolescent Referral Form Child InformationName of Child/StudentField is required!Field is required!Date of BirthField is required!Field is required!Name of SchoolField is required!Field is required!Grade LevelField is required!Field is required!GenderMaleFemaleUnknownField is required!Field is required!Ethnicity- select a option -American Indian/Alaska NativeAsianBlack/African AmericanEuropeanHispanic/Latin AmericanNative Hawaiian/Pacific IslanderPacific IslanderOtherWhiteField is required!Field is required!Name of InsuranceField is required!Field is required!Medicaid NumberField is required!Field is required!Legal Guardian/ParentParent/Legal Guardian:Field is required!Field is required!Parent/Guardian E-mail addressField is required!Field is required!PhoneField is required!Field is required!AddressField is required!Field is required!CityField is required!Field is required!ZipField is required!Field is required!Emergency ContactEmergency Contact Name:Field is required!Field is required!Phone NumberField is required!Field is required!BehaviorsPlease select all behaviors that apply:Physical AggressionVerbal AggressionSocial SkillsImpulsivity, excessive talkingProblems with concentration/focus/attentionHyperactivity, constant movingArgumentative, defiantBlames others for actionsClingy behaviorProblems with sleeping/eatingSubstance abuseExcessive lying, manipulationStealing, property destructionHand flapping, spinning objectsProcrastination, not completing tasksUnorganized, unwilling to keep assigned areas cleanSetting fires on purpose, running away from homeGives up easily, does not adapt to changeField is required!Field is required!Emotional NeedsPlease select all emotional needs that apply:Sadness, withdrawal from others, cryingLow self-esteem, negative self imageExcessive worrying, nervousnessPhobias, panic attacksQuick to anger, hostilityLow frustration tolerance, irritabilityIncreased avoidance of situationsRestless, always on edgeHistory of abuse, neglect, exploitationHistory of abandonmentExposed to family or community violenceSuicidal. homicidal, ideation, self-harmFlashbacks, nightmaresDisorganized, racing, bizarre thoughtsHearing voices, seeing thingsField is required!Field is required!How often are these behaviors occurring?- select a option -Several times a day1-2 times per weekseveral times per monthField is required!Field is required!Life FunctioningPlease select all that applyMedical/physical limitationsLearning disabilityExcessive expulsions suspensionsAble to dress self, maintain hygieneSleep DisturbanceLack of quality relationshipsHistory of arrests, judgementsAble to cook small mealsAble to clean home, laundryEating disturbanceField is required!Field is required!Additional Comments:Field is required!Field is required!ReferrerPerson Submitting Referral:Field is required!Field is required!Email:Field is required!Field is required!PhoneField is required!Field is required!Relationship to Client:Field is required!Field is required!Submit
