HomeMy WebLinkAbouticc-referral-english2000 Embarcadero Cove, Suite 400
Oakland, Ca 94606
510-567-8100 / TTY 510-533-5018
Karyn L. Tribble, PsyD, LCSW
Intensive Care Coordination (ICC) Referral Form
PLEASE email COMPLETED FORM TO
ICCAdministrator@acgov.org or FAX to 1 866 313-8448
This form is NOT to be used for open Child Welfare cases.
For child welfare clients, please consult with Child Welfare Worker regarding a Katie A. referral
The following supporting documents are required with this ICC referral:
MH Assessment Most Recent CANS
A discussion with client on the sharing of SUD and other sensitive information in the CFT meeting has occurred
Yes N/A
REFERRAL SOURCE
Date Person Referring Agency Relationship to Client
Phone# Email
CLIENT INFORMATION
Youth’s First Name Last Name DOB
Youth’s Address City Zip Code
Youth’s Phone Number
Preferred
Pronouns
CAREGIVER INFORMATION
Caregiver’s Name
ELIGIBILITY CRITERIA
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REASON FOR REFERRAL / CONCERNS
Please indicate if any of the following apply: (NOTE: these are not eligibility criteria) Child/Youth:
Is receiving/being considered for intensive mental health services, including but not limited to
Therapeutic Behavioral Services, Therapeutic Foster Care, Crisis Stabilization, Crisis Intervention, or
Wrap/Project Permanence
Is in a psychiatric hospital/24 hour mental health facility or discharged within past 90 days
Has had two or more mental health hospitalizations in last 12 months
Has been treated with one or more psychotropic medications over the past year
Has been detained pursuant to W&I sections 601 and 602 primarily due to mental health needs
Has received Specialty Mental Health Services (SMHS) within the last year and has been reported
homeless within the prior six months
Please describe specifically circumstances that require Intensive Care Coordination beyond what is
provided under standard mental health case management including need for cross system collaboration
and team facilitation:
RELEVANT CULTURAL FACTORS:
Danger to Self or Others Commercially Sexually Exploited Youth
Additional Comments:
CHILD AND FAMILY TEAM MEMBERS (as of date of referral) – if available
Team Member Name Telephone# email
Mother(s)
Father(s)
Caregiver/Guardian
Social Worker
Therapist
TBS Worker
Family Partner
School Staff
Medical
Other (please specify)