PPS 5115 QRTP Assessment Referral
SECTION I: Identifying InformationChild’s Name: FORMTEXT ?????Child’s DOB FORMTEXT ???? FORMCHECKBOX Male FORMCHECKBOX FemaleClient ID: FORMTEXT ?????Date Referred: FORMTEXT ?????Time Referred: FORMTEXT ????? FORMCHECKBOX AM FORMCHECKBOX PMFACTS Case Number: FORMTEXT ?????Permanency Goal: FORMTEXT ?????CINC Court Case Number: FORMTEXT ?????Judicial District: FORMTEXT ?????Parent/Caregiver Name: FORMTEXT ?????Parent/Caregiver Name: FORMTEXT ?????Address: FORMTEXT ?????Address: FORMTEXT ?????Phone: FORMTEXT ?????Phone: FORMTEXT ?????SECTION II: Agency Contact InformationReferring CWCMP Case manager: FORMTEXT ?????Phone: FORMTEXT ?????Address: FORMTEXT ?????Email: FORMTEXT ?????DCF Foster Care Liaison: FORMTEXT ?????Phone: FORMTEXT ?????Address: FORMTEXT ?????Email: FORMTEXT ?????SECTION III: Child’s Placement InformationDate of QRTP Placement: FORMTEXT ?????Name of Child’s Current Placement: FORMTEXT ?????Email Address: FORMTEXT ?????Address: FORMTEXT ?????Phone Number: FORMTEXT ?????SECTION IV: Other Individuals able to provide information on child’s functioning (IE: Foster Parents, School Personnel, Therapists, etc.)NameRelationship to ChildContact Information FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????SECTION V: Rationale for requesting an assessment for QRTP placement (Presenting problem and/or description of child’s behaviors) FORMTEXT ?????Attach all completed assessments to assist with the functional assessment of the child. These assessments may include, but are not limited, to the following: FORMCHECKBOX Structured Decision Making (SDM) FORMCHECKBOX Child Stress Disorder checklist-KS (CSDC-KS) FORMCHECKBOX Child Report of Post-Traumatic Symptoms (CROPS) FORMCHECKBOX Parenting Stress Index – Short Form (PSI-SF) FORMCHECKBOX Individual Education Plan (IEP) FORMCHECKBOX Child and Adolescent Functional Assessment Scale (CAFAS) FORMCHECKBOX North Carolina Family Assessment Scale (NCFAS)Once this form is complete please email to: QRTP@Call HealthSource Integrated Solutions Program administration support to discuss referral: 785-291-9138 ................
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