Screening and Referral Company Please check one New Current Child Name DOB Age Social Security Number: * Child's AddressMust be included on all Medicaid referrals to be able to run eligibility check. First Name Last Name Phone number Email Referral information: Where did you hear about us? DDS Worker Mental Health Contract Current ABS Transitions client Online search Social Media Independent research Other Behaviors of concern: 1 2 3 4 Current Diagnosis (please list all):: 1 2 3 4 Presenting Problem(s): Are there any urgent or critical needs of the client? Yes No Patient/student was referred to access emergency services (e.g. 911, emergency room): Yes No Funding Sources AvailablePlease check all that apply Medical (SSN must be included) Medicaid Insurance Private Pay State/Local Funding HOPE for Children and Families DDS Waiver OhioRISE Other
