THE ADOPTS CENTER: REFERRAL FOR SERVICES

REFERRING WORKER

Name
Organization
Phone Number
Email Address

CHILD'S BASIC INFORMATION

Name
Date of Birth
Address
Address 2
City
State
Zip
Phone Number
Sex
Race
Prim. Language
Adoption Type

  If Intercountry, from what country?

Primary Caregiver(s)

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

CHILD'S PLACEMENT STATUS

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

Relative Placement
Caregiver willing to participate in treatment?
Date child entered care
Date child entered current placement

# of placements child has had since entering care and duration of each:

FUNDING RESOURCES FOR CHILD'S PARTICIPATION IN ADOPTS

Please provide the information requested below for all insurance plans or subsidies for the child or parent,
public or private, that can be accessed to pay for ADOPTS services:
Type Available Name of Plan/Provider Member Name & DOB Member Number County (if applicable)
Medicaid
Children's Health Insurance Program
Adoption Subsidy
Private Insurance
Other

Indicate primary insurance plan:
Indicate secondary insurance plan:
If employer insurance, employer name:

Any other information related to health insurance or subsidies:

CHILD'S DIAGNOSIS

Under psychiatric care:
Psychiatrist's name:

Medication Dosage Prescribed By

INCIDENTS OF TRAUMA IN CHILD'S LIFE

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

PRESENTING BEHAVIORS (home, school, community)

CHILD AND FAMILY STRENGTHS

GOALS OF TREATMENT IN THE ADOPTS CENTER

ADDITIONAL INFORMATION REGARDING THE CLIENT