To expedite the referral process, social workers may fill out the forms below.
CASE WORKERS:
These are the forms that case workers need to fill out and return to get started with an appointment with the Foster Care Consultation Clinic. We also require records to be sent to hmcfcc@uw.edu. The required records are listed below.
1) Psychological Services Referral Form (to be completed by case worker and signed off by supervisor and area administrator)
3) Apple Health Coordinated Care ROI
5) Intake Form (fill out complete as possible)
Additional documents that we request for these evaluations include:
1) dependency petition, most recent
2) court report and intake, most recent
3) CHET
4) Child’s Medical and Family Background Report
5) medical records
6) birth records
7) birth certificate
8) mental health therapy records (in addition to past psychological evaluations)
9) school records (IEP initial evaluation and current plan or 504 Plan, if applicable)
CAREGIVERS:
Caregivers also have forms to fill out. These forms are a good place to start. There will be more forms emailed to you based on your child’s age and provider’s request.
1) Foster Care Clinic Parent Questionnaire (all ages)
2) Vanderbilt ADHD Assessment Form for kids ages 4+
3) Pediatric Symptom Checklist for kids ages 4+
TEACHERS:
The child’s teacher will typically have 2 forms to fill out, and ADHD assessment form for children ages 4+ and a Strengths and Difficulties form for ages 2-17. If your child has more than 1 teacher, feel free to distribute these forms to 1-2 additional teachers who know your child well. The more input, the better.
1) Vanderbilt ADHD Assessment Form for kids ages 4+
2) Strengths and Difficulties Ages 2-4