Referral Form / Pre-Mental Status Exam Information Sheet Page 2
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2Has the child had a physical with an MD? If yes, when? If no, please schedule ASAP.
Is the child currently taking medications? Would they need to be distributed at Northwest Journey?
Does the child have a mental health diagnosis? (please list, including who made the diagnosis and
when):
Are all providers in support of the referral?
SED Criteria (Must have at least 1 symptom and/or 2 functional impairments):
Psychotic Symptoms
Suicidality
Violence
Self-care functioning impairment
Social relationship functioning impairment
Community functioning impairment
School functioning impairment
Family functioning impairment
Services received and dates of service:
Juvenile Justice __/__/__ to__/__/__
Child Protection __/__/__ to__/__/__
Social Services __/__/__ to__/__/__
Special Education __/__/__ to__/__/__
Mental Health __/__/__ to__/__/__
Psychiatry __/__/__ to__/__/__
Previous or Current Services (obtain releases)
(School, MH providers, Human Services, Sheriff’s Dept., Insurance Company, Primary Physician,
Psychiatrist, In-home, guardian’s significant other, etc.)
Facility Name and
Contact
type of service
Address
Phone & E-mail
Person/Provider
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Form updated 6-13-11
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Parent category: Medical