Alternatives Referral Form
Please be sure to answer all the questions. If you need a follow up on a referral please contact Gabriela Saucedo, our Resource and Care Specialist, at gsaucedo@alternativesyouth.org or 773.853.9574.
Are you a school, primary care provider, parent, or other
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School
Primary Care Provider/Health Clinic
Parent/Guardian
Other
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School-Based Referrals
School administrators referring students over to Alternatives for therapy services. Please be sure to answer all questions. If you need a follow up on a referral, please contact our Resource and Care Specialist at gsaucedo@alternativesyouth.org or 773.853.9574.
Today's Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
School Name
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Name/Relationship AND contact information of person making referral
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Student's Legal Name
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Student's preferred name AND pronouns
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Student's Date of Birth
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student's primary language
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Student's phone number (please confirm that it is the correct number)
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Student's CPS email
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Student's insurance (please note if the student has private insurance, they may be referred out)
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Parent's name
Parent's primary language
Parent's contact information
Priority Referral (click all that apply0
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Suicidal/Homicidal Ideation
Self-harm/cutting
Physically abused***
Sexually abused***
None of the above
*As a mandated reporter, school personnel are required by law to contact the Abuse Hotline (1-800-25-ABUSE) to report suspected or disclosed abuse. What was the outcome of the hotline call? Please be sure to provide a copy of the CANTS 5 form to therapist. (Write N.A if no abuse was reported and no call was made).
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Is this student justice involved or at risk of being justice involved? (i.e. past or current legal involvement, current of part DCFS involvement, domestic violence, parent, is, or has been, incarcerated)
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Yes
No
Not sure
Check all that apply
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The student has used drugs and/or alcohol
The student has family members or significant others who use drugs and/or alcohol
The student has been in conflict with family and/or peers
The student has a history of being locked out of their home and/or running away
None of the above
If you've checked that the student has used drugs and/or alcohol, when was the last time? (Write N/A if not applicable)
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If you've checked that that student has family members or significant others who have used or are using drugs and/or alcohol, what is the relationship to the students (Write N/A if not applicable)
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If you've check that the student has a history of being locked out and/or running away, when was the last time (Write N/A if not applicable)
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Any additional information? (anything that would be helpful regarding why the referral is being made)
*
Submit
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Primary Care Provider/Health Clinic- Based Referrals
Health clinics or primary care providers referring students over to Alternatives for therapy services. Please be sure to answer all questions. If you need a follow up on a referral, please contact our Resource and Care Specialist at gsaucedo@alternativesyouth.org or 773.853.9574.
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Clinic Name
*
Name and contact information of provider making the referral
*
Youth's Legal Name (first, last)
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Youth's preferred name AND pronouns
*
Youth's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Youth's Phone Number (please confirm this is the correct number)
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Youth's email (optional)
Parent's Name (optional)
Parent's phone number (optional)
Parents primary language (optional)
Does the parent know about this referral?
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Yes
No
Reason for Referral
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Priority Referral (click all that apply)
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Suicidal/Homicidal Ideation
Self-harm/cutting
Physically abused***
Sexually abused***
None of the above
*As a mandated reporter, you are required by law to contact the Abuse Hotline (1-800-25-ABUSE) to report suspected abuse or disclosed abuse. What was the outcome of the hotline call? Please be sure to provide a copy of CANTS 5 for to therapist (Write N/A if no abuse was reported and no call was made).
*
Is this patient justice involved or at risk of being justice involved? (i.e. past or current legal involvement, current of part DCFS involvement, domestic violence, parent, is, or has been, incarcerated)
*
Yes
No
Not sure
Submit
Back
Next
Parent/Guardian or Other
Individuals referring themselves or someone else to Alternatives for therapy services. Please be sure to answer all questions. If you need a follow up on a referral, please contact our Resource and Care Specialist at gsaucedo@alternativesyouth.org or 773.853.9574.
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Organization Name (if applicable)
Name, Relationship AND contact information of person making the referral
*
Your name
*
Your relationship to youth/young adult
Youth/Young Adult's Legal Name
*
Youth/Young Adult's Preferred Name
Youth/Young Adult's Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Email
*
Preferred Method of contact/best call back time
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Youth/Young Adult's Zip Code
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Does the young person have health insurance (please note if you have private health insurance, you will most likely be referred out)
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Yes
No
Insurance Type
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Medicaid
Blue Cross Blue Shield of Illinois (MCO- Managed Care Organization)
CountyCare Health Plan (MCO- Managed Care Organization)
Harmony Health Plan (MCO- Managed Care Organization)
Illinicare Health (MCO- Managed Care Organization)
Meridian Health Plan (MCO- Managed Care Organization)
Molina Healthcare (MCO- Managed Care Organization)
NextLevel Health Partners (MCO- Managed Care Organization)
Private Health Insurance (HMO/PPO)
Other
Is this young person justice involved or at risk of being justice involved? (i.e. past or current legal involvement, current of part DCFS involvement, domestic violence, parent, is, or has been, incarcerated)
*
Yes
No
Not sure
The above information provided by you is necessary for starting your intake process. By checking this box, you acknowledge that you understand the information provided above will be accessible by Alternatives intake staff. This Staff will directly work with you to match you with appropriate care across Alternatives' network of services. Information you provide in this form is confidential.
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I understand
Submit
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