Functional Family Therapy (FFT) Referral

Referral Agency

Referrer Name

Referrer Email

Referrer Phone

Youth Name

Age

DOB

Gender

Race / Ethnicity

Languague Spoken at Home

Resides With (Full Name)

Relationship to Youth

Medicaid / Insurance
yesno

Insurance Information

Mobile #

Home #

Work #

Youth's Current Physical Address

City *Required*

Zip

Others in Home and Relationship to Youth

Referral Has Been Discussed With The Family?
Yes

Their Response?

Can they be available for early morning OR afternoon (3pm or 4pm) appointments?
yesno

Yes

Yes

At risk of out-of-home placement

Yes

Yes

Physical Aggression

Yes

Yes

Substance Abuse/Use

Yes

Yes

Negative Peer Associations

Yes

Yes

Theft

Yes

Yes

Verbal Aggression

Yes

Yes

Property Destruction/Vandalism

Yes

Yes

Runaway

Yes

Yes

Truancy

Yes

Yes

School Failure/Suspensions

Yes

Yes

Family Conflict/Discord

Yes

Yes

Mental Health

Yes

Yes

Recently discharged from hospital

Yes

Yes

Multiple mobile crisis or psychiatric ER visit/hospitalization

Yes

Yes

Has a pattern of hospitalization or
is at high risk of being hospitalized due to MH symptoms, behaviors, or undiagnosed or unmedicated MH concerns

Yes

Yes

Past history of treatment without much improvement within the last six months

Yes

Yes

Is at risk of IP/PHP or other residential settings

Yes

Yes

Has a Mental Health diagnosis

Yes

Yes

Does young person have an
active/ongoing psychosis, or active suicidality or homicidality?

Yes

Yes

Other