Clinical Behavior Consultation Screening & Referral Form

Contact Info

Contact information for the person submitting the referral

Referral Date *

First Name *

Last Name *

Agency *

Phone Number

Position

Email Address *

Enter Email

Confirm Email Address *

Confirm Email

Funding Start Date

*Please submit FAPT approval as soon as it becomes available to help expedite the assessment and service initiation process.

Funding Stop Date

Approved Hours

FAPT Funded Child

Name *

Date of birth

Race/ Ethnicity

Current School & Grade

Religious Affiliation

Language Affilliation

Current Address

Is the child in foster care?

Yes

No

Primary Caregiver/Service Recipient

Name

Age

Race/Ethnicity

Employer

Phone

Email

Religious Affiliation

Language Affiliation

Current Address

Relationship to Child

Biological Mother (If different from above)

Will Biological Mother be a service recipient? (if YES fill in information below)

Yes

No

Name

Age

Race/Ethnicity

Employer

Phone

Email

Religious Affiliation

Language Affiliation

Current Address

Biological Father (If different from above)

Will Biological Father be a service recipient? (if YES fill in information below)

Yes

No

Name

Age

Race/Ethnicity

Employer

Phone

Email

Religious Affiliation

Language Affiliation

Current Address

Additional Client Information

Primary Concern(s) for Referral (check all that apply)

Morning/Bedtime routines

Mealtimes/eating behaviors

Transition challenges

Cooperation difficulties

Communication/social engagement

Hygiene

Challenging behaviors

Other (please specify)Other (please specify)

Brief Description of Concern(s)

Current Support(s) in Place (check all that apply)

Goals for Consultation (What would you like to achieve through this consultation?)

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Clinical Behavior Consultation Screening & Referral Form