WOODWARD ACADEMY
NEW REFERRAL INFORMATION FORM

Name of person referring child:
Date of Referral:
Name of referral agency:
Title/Relationship to student:
Address City State Zip
Phone and Extension:
Is child receiving IA Waiver Services: Yes   No
Child's Name:
Gender:
Child's Age:
DOB:
Current Height / Weight
Is child receiving Special Education? Yes   No

Child's SS#:
Phone Number for Child:
Current Location:
State ID/Title 19 #:
Parent Name:
Parent Address:
Work Phone:
Cell Phone:
Home Phone:
Guardian Name:
Guardian Address:
Work Phone:
Cell Phone:
Home Phone:
Funding Source for treatment of child:
Name of Contact: Email Address: Phone Number:
Does child have IA Medicaid Coverage? Yes   No
Child's Most Current IQ score:
Child's Most Current Diagnosis:
Axis I    
Axis II  
Axis III - Current Medical Issues and Diagnosis:
List all Current Medications and dosage (separate with comma: i.e. Valporic Acid 5ml Morning & Night, Elavil 25mg 2x Daily):
History and Current Outpatient Treatment / Service Providers:
Agency Name:
Date of Service: to
 
Agency Name:
Date of Service: to
 
Agency Name:
Date of Service: to
History and Current Psychiatric Inpatient Treatment:
Name of Inpatient Treatment Facility:
Date of Service: to
Name of Inpatient Treatment Facility:
Date of Service: to
Name of Inpatient Treatment Facility:
Date of Service: to
Child demonstrates escalating problems of self injurious or assaultive behaviors as evidenced by:
Yes   No     Suicidal ideation and/or threat to self and/or others
Yes   No     Current self-injurious behavior
Yes   No     Evidence of physical aggression on self/others (scars, bruises, etc.)
Please send all questions and referral information to: Admissions.Woodward@sequelyouthservices.com.

A clinical decision cannot be made until collateral documentation is received.

Collateral Information can include, but is not limited to:

  • Predisposition Reports including a list of previous and current charges
  • Past and Current Placement progress/discharge reports
  • Current Individualized Education Plan (IEP) if the child is a Specialized Education Student.
  • Recent Psychological Evaluations including diagnosis and full scale IQ

Please Confirm you have read and understand the collateral documentation requirements.

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