The ADOPTS Center: Referral for Services

Information on the child you would like to refer

Name
Date of Birth
Address
Address 2
City
  State Zip
Phone Number
Sex
Internationally adopted? Yes No
  If Yes, from what country?

Primary Caregiver(s)

Name(s)
Address
Address 2
City
  State Zip
Phone Number
Email Address

Contact Person

Name
Phone Number
Email Address

Child's Placement Status

Temporary Foster Care Adoptive Home
Permanant Foster Care Residential Home
Pre-adoptive home
Other

Date child entered care
Date child entered current placement
List all placements child has had since entering care (Please include dates)
Child's Diagnosis (if known)

Funding resources to supplement child's participation

Community Mental Health Adoption Subsidy
Medicaid Priority Health Comp Care/Molina
FIA
Private Insurance
Other

Medications

Medication Dosage Prescribed By

Trauma experienced by child

Sexual abuse Traumatic loss
Physical abuse Familial violence
Emotional abuse Acute incidents (i.e. accidents)
Chronic neglect Medical Trauma
Parental Substance Abuse Exposure to war/terrorism/mass trauma
Parental mental illness Trafficking
Multiple disruptions of attachment
Other

Explain Traumas:

Counseling History

When Where With Whom How Long Reaction

Child's Behaviors (home, school, community)

Child and family strengths

Goals of treatment in the ADOPTS center:

What are your goals for this child's treatment?

Additional information regarding the child