Children’s Behavioral Solutions Patient Referral Form

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Patient Demographics
Gender
Legal Guardian Information
Patient Background Information
Is the patient being referred currently in treatment?
Does the patient being referred have a history of running away?
Does the patient being referred have a history of suicide attempts or ideation?
Does the patient being referred have a history of fire setting?
Does the patient being referred have a history of sexually inappropriate behavior
Does the patient being referred have a history of substance abuse?
Has the patient being referred experienced any major traumatic events or changes in his or her life (ie physical, sexual or emotional abuse, rape, significant illness, grief/loss)
Any current or past involvement in the legal system?

If no, please skip next section

Legal Issues
Does the patient have a juvenile court officer, probation officer, or court involvement?
Current Psychiatric Diagnosis
Does the patient have an Autism Spectrum Disorder (ASD) diagnosis?
Medical Diagnoses
Are there any health problems, allergies or physical limitations?
Previous Treatment
Has the patient had any of the following (check all that apply)
Educational Information
Enrolled in school?
Does the patient have an IEP, 504B, or other?

Combined total of all files may not exceed 7MB.

Primary Healthcare Information
Secondary Healthcare Information
Referral Documentation

Combined total of all files may not exceed 7MB.

How Did You Hear About Us
Have you been working with a Treatment Placement Specialist or Resource Coordinator with Children's Behavioral Solutions?
Name of person completing this form
Same as Legal Guardian?
Terms and Conditions

By submitting this referral form, you are giving permission for Acadia to research various treatment options for the patient you are referring. The information is completely confidential and a resource coordinator will be in contact with you shortly after reviewing the information suggesting the best treatment options.

Terms and Conditions Accepted

Our National Placement Services
  • Children's Behavioral Solutions
  • Military & Family Support Services
  • Treatment Placement Specialists

Our National Affiliations & Organizations
  • Commission on Accreditation of Rehabilitation Facilities (CARF)
  • National Alliance on Mental Illness (NAMI)
  • National Association for Behavioral Healthcare
  • National Association of Addiction Treatment Providers (NAATP)
  • The Jason Foundation
  • The Joint Commission (JCAHO) Gold Seal of Approval