Methodist Home for Children
Inspiring hope. Changing lives.
Note: All sections of this form must be fully completed before the referral can be processed. If information to a required question isn't available, simply enter 'N/A.'
Faxing this form is no longer required. Once the “submit” button is selected, the form responses will be directed to the appropriate staff.
Once you click "submit" you will be taken to a secure location to upload all necessary forms.
Individual Education Plan or Behavioral Intervention Plan from school if applicable
Attendance and/or suspension records
Treatment or Case plan
DJJ Risk and Needs Assessments
Client insurance card
Copy of birth certificate
Copy of Social Security card
Any applicable court documentation
Previous Comprehensive Clinical Assessments within the past year
Previous psychological evaluation (if youth has had one)
D/C summary or recommendations from previous providers (including psychiatric hospital or crisis stabilization)
Completion of the Initial Referral Form provides the assessment center administrative team with specific information sufficient to render an admissions decision. Additional information, clarifications, and assistance regarding the client, parent(s) / guardian(s), school, peers, home, community, and client's activities shall be requested over the course of the admitted client's assessment to aid development of each client's individualized service plan.
Once all documentation needed for a complete referral is received, someone from the assessment team will contact the court counselor and family to discuss the next steps; responses to received referrals generally occur within 48 business hours.
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Methodist Home for Children, Inc. | 1041 Washington Street, Raleigh, NC 27605-1259
phone 919.833.2834 | toll-free 888.305.4321 | fax 919.755.1833 | www.mhfc.org