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Instructions FCT Services Referral Form

Instructions FCT Services Referral Form

Table Of Contents
  1. Section 1: Referrer Information
  2. Section 2: PASSE & Case Coordination
  3. Section 3: Family Information and Household Members
  4. Section 4: Type of Case and Other Agency Support
  5. Section 5: Referral Behaviors and Concerns
  6. Section 6: Additional Notes & Sign-off

Section 1: Referrer Information

Please provide the contact details of the person completing this form. This information allows the FCT provider to confirm receipt of the referral and coordinate the next steps for the family.

  • Your Name: Enter your full name.
  • Your Agency Name: Provide the name of your organization or department. Leave blank fi you are a parent or caregiver.
  • Phone & Email: Enter your direct contact information so the provider can reach you quickly with updates.
  • Date of Referral: Select today’s date from the drop-down calendar. 
  • Referral Type: How urgently does this family need help?
    • Emergency: Family is in immediate crisis and requires contact within 24 hours.  
    • Regular: Standard processing, which requires contact within 48 hours.
  • Provider Selection: Check the box next to the specific agency you are requesting to handle this case. Each agency has a dedicated email address listed for submitting this form.
  • Submission: Once completed, email this form to the address listed under your selected provider.

Note: There are several factors that influence FCT provider assignments, so the FCT provider assigned may differ from initial selection.

Section 2: PASSE & Case Coordination

This section identifies the family’s PASSE (Provider-Led Shared Savings Entity) details.

  • PASSE Assigned to Identified Child: Select the checkbox next to the specific PASSE managing the child’s benefits.
  • PASSE Care Coordinator: Enter the full name, direct phone number, and email of the individual currently managing the child’s case. This person is a key partner in authorizing and reviewing services.
  • Care Coordinator’s Supervisor: Enter the contact information for the coordinator’s direct supervisor. This ensures a secondary point of contact is available to prevent any delays in service approval or communication.

Note: If you aren’t sure who the assigned coordinator is, you can usually find this information on the child’s insurance card or by calling the PASSE’s Beneficiary Support at 1-833-402-0672.

Section 3: Family Information and Household Members

This section confirms the family’s eligibility for services and provides the demographic details needed to open the case. FCT is a family-based model, so information for all household members is required.

  • Eligibility Check: Verify and check all three boxes. To qualify, the family must have:
    • A child aged 4–17 with a behavioral health need.
    • At least one caregiver willing to participate in therapy.
    • A goal to either prevent the child from leaving the home or to bring them back home safely from a placement.
  • Address & County: Provide the primary residence where the family lives. The county is used to ensure the assigned agency covers that specific service area.
  • Independent Assessment (IA): Enter the date of the child’s most recent IA and check whether it was for Behavioral Health (BH) or Developmental Disability / Intellectual Disability (DD/ID).
  • DD/ID Concerns: If the child has a known or suspected developmental disability (like Autism or a cognitive delay), check “Yes” and provide a brief description. This helps the provider coordinate specialized supports for the family.
  • Caregiver & Adult Details: List the primary adults in the home first. Then, list any other adults living in the home (such as an adult sibling or relative). Include backup phone numbers to ensure the provider can schedule the first visit without delay.
  • Children & Identification:
    • List the child receiving the referral first.
    • Enter that child’s Medicaid ID, PASSE ID, and Social Security Number.
    • List all other children living in the household, including their schools, as they will also be involved in the family therapy process.

Section 4: Type of Case and Other Agency Support

Family Centered Treatment (FCT) is designed to coordinate with other state systems to provide a “no-gaps” support network. Use this section to explain why the family is being referred now and who else is currently working with them.

  • Type of Case: Check the box that best describes the family’s current situation:
    • Prevention of Removal: The child is currently in the home but is at high risk of being removed due to safety or behavioral concerns.
    • Reunification: The child is currently in an out-of-home placement (like foster care) and FCT is being used to help them move back home safely.
    • Pre/Post Adoption: The family needs support to stabilize a pending adoption or an already finalized one.
    • Post Residential: The child is transitioning back home after staying in a residential treatment center or hospital.
  • Language & Interpreters: Specify the primary language spoken in the home. If an interpreter is needed, check “Yes” and add any specific notes (e.g., “The caregivers speak Spanish, but the children speak English”) so the provider can assign the right staff or make arrangements for interpreter services.
  • System Involvement: Check Yes or No. If involvement is unknown at this time, please mark ‘No’ and add a note in the details section, or leave a comment indicating information pending.
    • For DCFS, DYS, Probation, or Court, you must provide the contact details for the assigned worker or officer. Is Family Center Treatment (FCT) / Intensive In-Home Services (IIHS) court ordered for the identified child? This allows the FCT Practitioner to ensure all applicable agencies are included in monthly child and family team meetings.
    • Mental Health / Substance Abuse Treatment Services: If the child is already seeing a therapist or is getting substance abuse treatment services, check yes. Check no if they do not see anyone for mental health or substance abuse treatment services.
      • Current Agency: Enter the name of the agency/clinic where the child gets their therapy.
      • Clinic-based: Check this box if the child goes to a private office or clinic for their therapy appointments.
      • School-based: Check this box if a therapist comes directly to the child’s school to see them during regular school day.
      • Therapist: Enter the name of the therapist who meets with the child.
      • Qualified Behavioral Health Professional (QBHP): Enter the name of the child’s behavioral coach or skill-builder. A QBHP works the therapists plan to give the child hands on practice with coping skills, anger management, and social skills at school or home.

Section 5: Referral Behaviors and Concerns

This section provides the “clinical picture” of why the family needs intensive in-home therapy. The information you provide here helps the provider determine the urgency of the case and the specific skills the therapist will need to use.

  • Check and Describe: Please write a detailed description for each box you check. A high-quality referral includes:
    • Who: Which family member is displaying the behavior?
    • What: What exactly is happening?
    • When: Is this recent  or new behavior or has this been going on for the last year?
    • Impact: How is this behavior affecting the family’s safety or ability to stay together?
  • Specific Situations:
    • Hospitalizations: If a child was recently in an acute psychiatric hospital, list the name of the facility, the dates they were there, and what the discharge plan recommended.
    • Sexual Behaviors: If checking this box, please include any safety plans currently in place and the results of any specialized assessments.
    • Trauma: Briefly note if there is a history of abuse, neglect, or significant loss that is currently impacting how the family functions.
    • Substance Use: Identify which family member is using substances and how it is interfering with parenting or child safety.

Note: Focus on recent events (the last 30–90 days) to show why the family needs the “intensive” level of care that FCT provides rather than standard outpatient therapy services.

Section 6: Additional Notes & Sign-off

Use this final section to provide a well-rounded view of the family and to officially authorize the referral. FCT focuses on building upon what is already working, so your insights here are very valuable.

  • Family Strengths: List what the family does well. This could include strong bonds between siblings, a caregiver’s commitment to change, or the family’s involvement in a church or community group.
  • Support System & Extra Members: If the household is large or if there are influential relatives (like a supportive grandmother or an active mentor) who aren’t listed in Section 3, include them here.
  • Foster Care Placement: If the child is currently in foster care, provide the name and contact info of the foster parents and the address of the placement. This helps the practioner know where to conduct the initial visits.
  • Other Pertinent Info: Use this “catch-all” space for anything else the provider should know. For example: “The family has a friendly but large dog,” or “The father works night shifts and is only available for sessions after 4:00 PM.”
  • Signature: Sign and date the form. Your signature confirms that the information provided is accurate to the best of your knowledge and that you are formally requesting these services for the family.

Download as PDF and email to selected provider.