Extended Day Treatment Referral Form 
 
If you are a DCF Social Worker or System of Care Coordinator, please provide past treatment records, reports and/or evaluations.          

Please contact us with any questions,


Lenka Villanueva, 203-248-2116 ext 277  [email protected].

Marissa Kosh, 203-248-2116 ext 373  [email protected].

                                                
* Required Fields
REFERRAL SOURCE- If DCF Complete this section
  DCF Social Worker 
* DCF Office, enter none if not applicable 
  Work Phone 
  Email 
  DCF Supervisor 
  DCF Supervisor Phone 


REFERRAL SOURCE- If not DCF, Complete this section
  Name 
  Agency 
  Phone 
  email address 


CHILD AND FAMILY INFORMATION
* Child's Name 
* Date of Birth 
  Child's Gender 
* Child's address 
  Child's phone 
  Child's SS# 
  Child's DCF Link Number 
* Child's Primary Insurance 
* Primary Insurance ID# 
  Secondary Insurance 
  Secondary Insurance ID# 
* Child's Primary Language 
* Parent Primary Language 
* Parent-caretaker's Names 
  Parent-Caretaker's address if different than child's 
* Parent-Caretaker's home phone 
  Parent-Caretaker Work Phone 
* Parent-caretaker relationship to child 
* Parent-caregivers are informed of family involvement requirement 


PERSONS LIVING IN HOME
* Name and relationship of person living in home with Child 
  Name and relationship of person living in home with Child 
  Name and relationship of person living in home with Child 
  Name and relationship of person living in home with Child 
  Name and relationship of person living in home with Child 


ETHNICITY
  Please check one that best describes child's ethnicity 


CHILD'S MENTAL HEALTH /MEDICAL ISSUES
  Child's Diagnosis 
  Who gave the child this diagnosis? 


CURRENT TREATMENT PROVIDERS
  If the child is currently in treatment, please list name of provider, agency and contact info 
  If the child has a current Psychiatrist, please provide name and contact information 


PAST TREATMENT PROVIDERS
  Please list where and when the child has received prior treatment 


DESCRIBE ANY CURRENT MEDICAL CONCERNS
  Please describe any current medical concerns 


MEDICATION
  Th child is currently prescribed medication (physical or behavioral health) 
  Please list medications prescribed to the child 
  Name and phone number of Pediatrician 


OTHER AGENCIES /PROGRAMS INVOLVED
  Please list other agencies or programs involved with the child and describe services provided 


SCHOOL CONTACTS
* Name and town of School 
  Contact person and phone number at school 
  The child receives special education 
  Full Scale IQ if known 


PROBATION OR PAROLE OFFICER
* Child is assigned a Probation or Parole Officer 
  Name and phone number of Officer 


TRAUMA HISTORY
* The Child has experienced 
  If multiple traumatic experiences, please list here 


PRESENTING CONCERNS
* The child experiences the following currently 
  If multiple concerns, please describe here 
* Please indicate if the child has a history, but no longer experiences the following 
  If multiple prior concerns, please list here 


CHILD'S STRENGTHS
* Please describe child's strengths 


CHILD's CURRENT DCF STATUS
* Child's Current DCF Status (check one) 


ADDITIONAL INFORMATION
  Please provide any additional information you believe will be helpful 




 
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