TDT Referral Form EmailThis field is for validation purposes and should be left unchanged.Therapeutic Day Treatment (TDT) Office: (540) 488-5636 Fax: (888) 808-3395 Instructions: For New TDT Students, please complete all sections of the referral form. For Returning TDT Students, update any new information for page 1 (if no changes, check “no known changes” box and complete all sections of the remaining pages with current school year information).Type of Referral New TDT Student Returning TDT Student Student Information No Known Changes Student NameDate of Birth: MM slash DD slash YYYY Gender:Legal Guardian:Relationship:Street Address:City/State/Zip:Phone Number:Alternate Number:Medicaid ID:MCO:Referral Source School:Name:Title:Email Contact Number:Medical InformationCurrent Medications No Known Changes NameDosagePurposeNameDosagePurposeNameDosagePurposeCurrent Diagnoses No Known Changes PrimarySecondaryTertiaryMedical ProvidersNameType of ProviderPhone NumberNameType of ProviderPhone NumberNameType of ProviderPhone NumberSchool Information Grade LevelIEP/504 Plan?Number of Unexcused Absences this School YearNumber of In School Suspensions (Past 6 Months)Number of Out of School Suspensions (Past 6 Months)Number of Classes Currently TakingNumber of Classes Currently FailingNumber of Classes Currently PassingCurrent / Past ServicesType of ServiceService ProviderDates of Service MM slash DD slash YYYY Dates of Service MM slash DD slash YYYY Outcomes/ ProgressMinimal ProgressModerate ProgressSignificant ProgressNon-CompliantService Never StartedType of ServiceService ProviderDates of Service MM slash DD slash YYYY Dates of Service MM slash DD slash YYYY Outcomes/ ProgressMinimal ProgressModerate ProgressSignificant ProgressNon-CompliantService Never StartedType of ServiceService ProviderDates of Service MM slash DD slash YYYY Dates of Service MM slash DD slash YYYY Outcomes/ ProgressMinimal ProgressModerate ProgressSignificant ProgressNon-CompliantService Never StartedType of ServiceService ProviderDates of Service MM slash DD slash YYYY Dates of Service MM slash DD slash YYYY Outcomes/ ProgressMinimal ProgressModerate ProgressSignificant ProgressNon-CompliantService Never StartedType of ServiceService ProviderDates of Service MM slash DD slash YYYY Dates of Service MM slash DD slash YYYY Outcomes/ ProgressMinimal ProgressModerate ProgressSignificant ProgressNon-CompliantService Never StartedBehavioral Concerns Self-Harm Struggle with Concentration Difficulty with Interpersonal Relationships Hospitalization in Past Year Inappropriate Social Behavior Suspected Child Abuse/Neglect Aggression towards others Depression Threats to Harm Self or Others Disruptive Behaviors Anxiety Defiant with Authority Drug/Alcohol Use Poor Impulse Control Hyperactivity Threat Assessments Social Skill Deficits Truancy Concerns At Risk of Homebound At Risk of Long-Term Suspension Inability to Recognize Personal Danger Trauma History Court Involvement / CHINS Active CPS Involvement Loss/Grief Anger Inability to Adjust / Transition Behavior Description Please provide intensity, frequency, and duration of the behavior identified above.Other Concerns Please provide information on any other behaviors or mental health related concerns (substance abuse issues, personality disorders, or cognitive impairment) not mentioned above. Requested DocumentationPlease provide all of the following documents that are applicable with referral form. Current Grades Current Attendance Incident Reports RTI/FBA/BIP Behavioral Data Log Entries Other Supporting Data SignatureReferral Source Signature:Date Signed: MM slash DD slash YYYY CAPTCHAUpload FileMax. file size: 512 MB.
