North Sound YNP

24-hour Crisis line: 1 (800) 584-3578

FOR PROVIDERS ONLY

Have you obtained an ROI from the youth and / or Legal Guardian to release the information that is required for this form? If so, please click the checkbox below:

I have obtained the required ROI

Do you prefer Email / Text / Phone call?^*

May we leave sensitive information?^*
Yes No

Best time to reach you^*

Relationship to youth^*

(Check all that apply)

Legal Guardian/Caregiver
Crisis Response Staff
WISE Provider
School Personnel

Therapist
Medical Personnel
Hospital Staff

Other

Release of Information (ROI) completed^*
Yes No
ROI MUST be signed by youth if 13 years old, or
by LEGAL guardian if 12 or under.

First Name of Youth^*

Last Name of Youth^*

Youth Birth Date^*

Youth Address (line 2)

Legal Guardian First Name^*

Legal Guardian Last Name^*

Legal Guardian Phone^*

Legal Guardian Email^*

Race / Ethnicity^*

Tribal Affiliation^*

Preferred Language^*

Interpreter Needed^*

County of Residence^*

Primary Care Physician (PCP)?^*
Yes No

Mental health Counselor?^*
Yes No Not Sure

Youth currently at Emergency Department?^*
Yes No

Is Youth involved with Special Education?^*

Home School District

Home School Representative

Home School Name

Treatment Interventions (current and historical)?^*

(Check all that apply)

Psychiatric Hospitalizations
Residential Treatment
Partial Hospital Program (PHP)
Wraparound with Intensive Services (WISe)
Outpatient

CLIP Admission
ER visit for Behavioral Health
Intensive Outpatient Program (IOP)

Other

Strengths / Interests?^*

Presenting Symptoms^*

(Check all that apply)

Physical Aggression
Threatening Behaviors
Anxiety
Inappropriate sexual behaviors
Self-Harm Behaviors
School Attendance Issues
Medication Non-Compliance
Auditory / Visual Hallucinations
Suicidal Thoughts / attempts

Verbal Aggression
Impulsivity
Depression
Treatment Non-Compliance
Run Away / elopement
Homicidal thoughts / Gestures
Trauma
Abuse / Neglect
Drug / Alcohol Concerns

Other

What is the current concern?^*

Desired outcomes of referral?^*

Developmental Disabilities Involved?^*
Yes No

Involved in the Legal System?^*
Yes No

Department of children Youth & Families (DCYF) Involvement?^*
Yes No
If Yes, enter DCYF name:
If Yes, enter DCYF phone number:

Natural Support Systems:^*

Other useful Information:

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Submit Referral

Youth Navigator Referral Form

FOR PROVIDERS ONLY