Download ICM referral form

CORTLAND COUNTY CHILDREN’S SERVICES REFERRAL PROCESS
1. Please complete the Children’s REFERRAL packet as thoroughly as possible. Make sure to include the signed Release of
Information Form. If you are unsure of certain information or do not have access to all information, the referral can still be
submitted and reviewed. An electronic version can be found at: http://www.cortland-co.org/mhealth/Default.htm
2. Make sure to indicate the service(s) being requested (if known). See below for listing of services available through Cortland
County.
WHERE TO SEND REFERRALS
3. When requesting Liberty Resources, CCSI, or DSS Preventive services please fax or email the completed referral and
the attached release to:
Fax: (607)-753-5121
Email: [email protected] & [email protected]
Mail: 60 Central Ave. Cortland, NY 13045 att. Maureen Spann & Christopher Driscoll
4. When requesting any SPOA services please fax, email, or mail the completed referral and the attached release to:
Fax: 607-758-6116
Email: [email protected]
Mail: Child SPOA, 7 Clayton Ave. Cortland, NY 13045 att. Alexandra Huntington-Ofner
5. When requesting any combination of SPOA services with Liberty Resources, CCSI or DSS Preventive Services please
send referrals to Alex Huntington-Ofner, Maureen Spann & Chris Driscoll.
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CHILDREN’S SERVICES AVAILABLE IN CORTLAND COUNTY
Family Support Services (includes 5 separate services)--Jamee Sobko, Director (607) 758-6110 x228
(Individuals may make direct referrals to this program as well. Contact Director at number above)
 One-to-one Respite--provides trained Mental Health Program Aides to work one-on-one with an at-risk youth for
approximately 2-3 hours per week. Activities depend on the interests and needs of the child.
 TEAM In -Home Parenting--provides parenting support, advice, and techniques by a trained individual in your home
setting.
 Drop In Respite--provides eligible children with a structured, fun afternoon each week with trained workers. Children
are placed in age appropriate groups and activities vary each week.
Coordinated Children’s Service Initiative (CCSI)-A trained Parent Partner with lived experience works alongside
families to bring service providers together in order to create a coordinated, comprehensive and strength-based family plan
that utilizes multiple systems. The Parent Partner works alongside parents to support them through whatever adversity they
may be dealing with. A child must be working with multiple services providers or be at risk of out of home placement
through any system in order to access CCSI services.
DSS Preventive Services--Provides a Caseworker to address the risk and safety issues present in identified families in
order to prevent the foster care placement of children. Efforts are undertaken to coordinate and integrate the family with
community services and resources. If foster care placement is unavoidable, intensive services are provided in an effort to
reunite the family or to achieve another form of permanency.
Liberty Resources
 Placement Diversion--A licensed family therapist will provide in-home family therapy and support to families with a
youth exhibiting PINS type behavior in order to prevent an out of home placement.
 Detention Reunification--A licensed family therapist will provide family therapy and support to a family with a youth
placed in Detention in order to expedite their return home.
Below are the services available to eligible* children, ages 5 through 18, who are referred to SPOA:
*Eligible means child must have DSM IV Axis I Diagnosis and be determined Seriously Emotionally Disturbed (SED)
5. Intensive Case Management--provides case management for eligible* children. There are 36 ICM slots in Cortland
County, with each case manager working with 12 children. Intensive Case Managers help families coordinate necessary
services for their children such as medication management, counseling, and education, as well as desired programs,
activities, and recreation.
6. Home and Community Based Services Waiver--provides the highest level of community based service for eligible*
children. Individual Care Coordinators work with the family to develop a service plan based on the family's unique
strengths and needs. Some of the services families can choose from include: Family Support Services, Crisis Response
Services, Intensive Home Services, Skill Building Services, and Respite Care. There are 12 slots in Cortland County
for this service and average length of involvement in the program is approximately one year.
7. Residential Treatment Facility Programs--if all Community-based services have been considered or
tried and the child still cannot be maintained in the community, an application to Residential Treatment Facility can be
made. The SPOA committee determines if the RTF referral is appropriate and sends out the referral packet to the Office of
Mental Health Pre-Admission Certification Committee (PACC). Other agencies may need to assist in gathering
documentation and information for the referral packet.
Revised March 2015
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Family and Youth Services Referral
Application for:
Liberty Resources
CCSI
Placement Diversion
Detention Reunification
DSS Preventive Services
Parent Partner
Preventive Caseworker
SPOA Services
Cortland County Mental Health Family Support Services
Catholic Charities Intensive Case Management
Hillside Waiver’s Home & Community Based Waiver
Residential Treatment Facility
Referring Contact Person:
Phone:
Referral Date:
Email:
Child Data
First Name:
Last Name:
D.O.B:
Age:
Gender:
Child’s School:
School Phone:
Grade:
Contact Person:
Family Data:
In Custody Of:
Relationship to Child:
Address where Child Resides:
Phone:
Note Best Times to Contact Family:
Cell:
Others in Home: Please list siblings, step-parents, all immediate family, and people living in the house.
Name:
Age:
School:
Grade:
Relationship:
Revised March 2015
Address If Different:
Contact Number:
2
Probation and JD Charges Information: (if any)
Who filed PINS petition?
Date:
Current Family Court Status:
JD Charge?
Yes
No
Court Return Date:
Please list any service providers involved with this family:
Agency:
Contact Person:
Telephone Number:
Mental Health Treatment History  Check if unknown
Hospital ER or Psychiatric Hospital
Where?
Dates? How long? Therapist?
Admissions
Inpatient Hospitalizations
Psychiatric ER Visits
Outpatient Treatment
Intensive/ Supportive Case
Management
Home & Community Based Waiver
Program
Therapeutic Foster Care
Crisis Calls
Number in last
year?
1. Please give a brief description of the presenting problem or the reason for referral.
2. Please discuss child’s status with Probation Department and Family Court system.
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3. Please describe the family strengths and supports that may be utilized in services provision (interests,
hobbies, personal attributes, family accomplishments, relatives, community organization).
4. What do you think the family’s needs are:
Behavioral:
Social:
Academic (please discuss any psychological testing, CSE classifications, or attendance needs/concerns) :
Mental Health (please include diagnosis):
Medications:
Other (Parenting skills, Housing, Financial, etc.):
5. How do you think services can best meet those needs?
6. What do you think have been the barriers to increased stability for this family (please specify the
caretaker’s level of involvement)?
7. Please, list any CONCERNS you have in regards to this family that should be addressed immediately:
Referral Source Signature:
Phone Number:
Date:
Supervisor Signature (if applicable):
Phone Number:
Date:
Revised March 2015
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AUTHORIZATION FOR
RELEASE OF INFORMATION
Patients Name (Last, First)
………………………………………………
Sex:……………………..Date of Birth………………….
Facility Name:…………………………………………….
This authorization must be completed by the patient or his/her personal representative to use/disclose protected health information, in accordance with
State and Federal laws and regulations. A separate authorization is required to use of disclose confidential HIV related information.
______________________________________________________________________________________________________________
Description of Information to be used/Disclosed: Any psychiatric and/or psychological testing (including IQ), discharge
planning, psychosocial summaries, special education documentation or other relevant information in order
to assist with determining eligibility.
Purpose or Need for Information:
1. This information is being requested:
 by the individual or his/her representative; or
X Other (please describe) by the Cortland County Children's Services including
SPOA committee, Mental Health Services Clinic 7 Clayton Avenue Cortland, NY 13045
Liberty Resources, 60 Central Ave Cortland, NY 13045 CCSI, 60 Central Ave Cortland, NY 13045
Cortland County DSS, 60 Central Ave Cortland, NY 13045
Children’s Services Agencies who will have access when appropriate will include: Community Services- Liberty Resources, CCSI, Cortland County DSSPreventive; Mental Health services--specifically SPOA coordinator, Intensive Case Managers, Clinicians, Family Support Services, Franziska Rackers at
BOCES, Department of Social Services, Catholic Charities, Hillside Waiver, Office of Mental Health, Family Counseling Services, Central New York DDSO,
and Director of Community Services.
Youth’s School (List names of Counselors, Principals, or teacher(s): _______________________________________________________
OTHER specific to this referral: ____________________________________________________________________________________.
2. The purpose of the disclosure is (please describe):
To assess eligibility for community services for children as listed above in children’s service membership and to assess priority for receiving community
services.
OTHER: ______________________________________________________________________________________________________.
Organization/Facility/Program Disclosing Information:
From-please check all that apply
To: Cortland County Children’s Services
(membership listed above)
Coordinated Children’s Services Initiative
Cortland Regional Medical Center
Cortland County Mental Health
School District
Cortland County DSS
Cortland County Probation
Catholic Charities
_____Family Counseling Services
Liberty Resources- Placement Diversion and Reunification
Other-please specify
A.
I hereby permit the use or disclosure of the above information to the Person/Organization/Facility/Program(s) identified above. I understand that:
1. Only this information may be used and/or disclosed as a result of this authorization.
2. This information is confidential and cannot legally be disclosed without my permission.
3. If this information is disclosed to someone who is not required to comply with federal privacy protection regulations, then it may be redisclosed and would no longer be protected.
4. I have the right to revoke (take back) this authorization at any time. My revocation must be in writing on the form provided to me by the
agency I am working with. I am aware that my revocation will not be effective if the persons I have authorized to use and/or disclose my
protected health information have already taken action because of my earlier authorization.
5. I do not have to sign this authorization and that my refusal to sign will not affect my abilities to obtain treatment from the
New York State Office of Mental Health, nor will it affect my eligibility for benefits.
6. I have a right to inspect and copy my own protected health information to be used and/or disclosed (in accordance with the requirements of
the federal privacy protection regulations found under 45 CFR 164.524).
B-1. One-Time Use/Disclosure: I hereby permit the one-time use or disclosure of the information described above to the
person/organization/facility/program/committee identified above.
My authorization will expire: 
When acted upon

90 Days from this date;

Other ____________________________________________________________
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AUTHORIZATION FOR RELEASE OF INFORMATION
Facility Name/Agency
Patient/Client Name (Last, First, M.I.)
B-2. Periodic Use/Disclosure: I hereby authorize the periodic use/disclosure of the information described above to the
person/organization/facility/program identified above as often as necessary to fulfill the purpose identified above.
My authorization will expire:
 When I am no longer receiving services from: Cortland County Children's Services (listed on other page).
 One year from this date;
 Other _________________________________________________________________________________________________
C.
Patient Signature: I certify that I authorize the use of my health information as set forth in this document.
______________________________________________________________________
(signature of patient/client or personal representative)
_________________________
(date)
_____________________________________________________________________
Patient/Client name Printed
______________________________________________________________________
Personal Representative's Name (printed)
_______________________________________________________________________
Description of Personal Representative's Authority to Act for the Patient/Client (required if personal representative signs)
D.
Witness Statement/Signature: I have witnessed the execution of this authorization and state that a copy of the signed authorization was
provided to the patient/client and/or the patient/client's personal representative.
WITNESSED BY: ________________________________________________________________Date: _______________________
Signature of staff person using/disclosing information
Authorization Provided to: Cortland County Children's Services (membership listed on other page).
To be completed by facility or agency:
______________________________________________ _______________________________________
(Signature of staff person using/disclosing information
Title
_____________________
Date
PART 2: REVOCATION OF AUTHORIZATION TO RELEASE INFORMATION
I hereby refuse or revoke to authorize the use/disclosure indicated in Part I, to the Person/Organization/Facility/Program whose name and address is:
Children's SPOA Committee OR
Mental Health Services
Cortland County DSS
Preventive
7 Clayton Avenue
Cortland, NY 13045
60 Central Ave
Cortland, NY 13045
or
Liberty Resources
Placement Diversion
and Reunification
60 Central Ave
Cortland, NY 13045
______________________________________________________________________
(signature of patient/client or personal representative)
or
CCSI
Parent Partner
60 Central Ave
Cortland, NY 13045
_________________________
(date)
_____________________________________________________________________
Patient/Client name Printed
______________________________________________________________________
Personal Representative's Name (printed)
_______________________________________________________________________
Description of Personal Representative's Authority to Act for the Patient/Client (required if personal representative signs)
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