BERNALILLO ACADEMY
NEW REFERRAL INFORMATION FORM

Haga clic aquí para completar el formulario en español

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 NM 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#:
County of Residence:
Address where child currently lives:
Parent Name:
Parent Address:
Work Phone:
Cell Phone:
Home Phone:
Guardian Name:
Guardian Address:
Work Phone:
Cell Phone:
Home Phone:
Does Parent/Guardian have commercial insurance coverage for RTC?
Yes   No
Policy#:
Group#:
Funding Source for treatment of child: Commercial Insurance   School District   Children's Social Services   Other  
Does child have NM Medicaid Coverage? Yes   No
If you have chosen a Salud, which one: Presbyterian   BC/BS   UBH   Molina
If you have Medicaid coverage for the child from a state other than NM that the child currently lives in, indicate which state: and the Medicaid#
Date of Medicaid Recertification for this child:
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
Name of Contact and phone#:
 
Agency Name:
Date of Service: to
Name of Contact and phone#:
 
Agency Name:
Date of Service: to
Name of Contact and phone#:
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 FAX TO: 505-768-7956 or SCAN COLLATERAL DOCUMENTATION TO: alison.cdebaca@sequelyouthservices.com AS QUICKLY AS POSSIBLE AFTER COMPLETION OF THIS FORM.

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

Collateral documents include, but are not limited to:

  • Most recent Psycho-educational testing or diagnostic reports (within the last three years)
  • Most recent Psychological/Neurological evaluations (preferably within the last 3 months)
  • Current Individualized Educational Plan (IEP) if enrolled in Special Education
  • Current Treatment Plans

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

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