Form 4746t - Mental Health Referral - Riverside County Division Of Children And Family Services

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Division of Children and Family Services
Early Childhood Education Programs
Mental Health Referral
Date of Referral: ________________________________________ Head Start Site: _______________________________________
Child’s Name: _________________________________________ Birthdate: ____________________________________________
Parent/Guardian Name: _________________________________ Phone: ______________________________________________
Language spoken in the home:  English  Spanish  Other: ___________________________________________________
Teacher: ______________________________________________ Responsible Staff: ______________________________________
Consulting agency and/or wellness specialist assigned:_______________________________________________________________
Reason for Referral: (Please indicate)
 Child referral Parent referral
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Please check any behaviors that you are concerned with. Describe situation and frequency in the space provided.
 Hitting
 Kicking
 Slapping
 Pinching
 Biting
 Seldom or never speaks
 Spitting
 Shortness of Breath
 Tantrums
 Crying
 Screaming
 Vomiting/Nausea
 Cursing
 Defiant
 Runner
 Persists at one activity
 Restless
 Bitting Nails
 Fearful
 Anxious
 Unable to sit for activities
 Stomach Issues/Pain
 Urinating
 Withdrawn
 Tense
 Difficulty with transitions
 Lacks Concentration
 Climbs on furniture
 Throws things
 Sleep Issues (Reported by parents)
Destructive Behavior
 Hurts self
 Hurts other children
 Hurts adults
 Breaks objects or toys
Difficulty getting along with other children
 Bothers or interferes with others
 Grabs other children or toys
 Crashes into other children
 Avoids other children; does not interact
 Is avoided by other children (Other children avoid child)
 Aggressive play/irritable
Difficulty getting along with adults
 Clings to adult
 Avoids adults; does not interact with them
 Other:
_________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Office Use Only
Date Received: ___________________
Log Number: _____________________
Log Number Entry Date: _________________
FORM NO. 4746T
(Revised 12/13)

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