COST Form

CONFIDENTIAL

COST REFERRAL FORM

If you suspect Child Abuse or Neglect, YOU MUST notify Children and Family Services at 510-259- 1800

Name *

Is youth/member aware of referral? *

Yes

Today's Date *

Date of birth *

Age *

Caregiver name / relationship *

Is caregiver aware of COST referral? *

Yes

Caregiver contact number *

Youth contact number *

REACH Member? *

Yes

Siblings at REACH? [Enter names here]

Address *

City *

State / Zip Code *

Name/title/contact info of person making referral *

Primary Language of Youth *

Primary Language of Guardian *

Is a translator needed? *

Yes

Concerns & Obstacles

(Answering 'Yes' to any of these fields will trigger other fields for you to check or fill in)

Academics/Vocational

Ongoing Academics/Vocational Concern? *

Yes

Recent Academic/Vocational Changes? *

Yes

Approx. date of Academics/Vocational change *

Academics/Vocational Changes *

Academics/Vocational Concerns & Obstacles

Existing IEP

Existing 504 Plan

Insufficient Credits

Suspensions/Expulsions

Behavioral Dysregulation

Trouble Focusing/Paying Attention

Conflicts with Authority

Chronic Lateness/Absences

Lack of Access to System Supports (e.g., IEP, 504, work permits)

Other Academics/Vocational Accommodations *

Learning Difficulties (Subjects) *

Other Academics/Vocational Concerns (Please explain) *

Emotional/Mental Health

Ongoing Emotional/Mental Health Concern? *

Yes

Recent Emotional/Mental Health Changes? *

Yes

Approx. date of Emotional/Mental Health change *

Emotional/Mental Health Changes *

Other Emotional/Mental Health Concerns (please explain) *

Social

Ongoing Social Concern? *

Yes

Recent Social Changes? *

Yes

Approx. date of Social change *

Social Changes *

Other Social Concerns (please explain) *

Health/Basic

Ongoing Health/Basic Concern? *

Yes

Recent Health/Basic Changes? *

Yes

Approx. date of Health/Basic change *

Health/Basic Changes *

PRIOR INTERVENTIONS AND RECOMMENDATIONS

Indicate at least 3 Interventions before making referrals

Interventions (what have you tried?)

Talked with member one-on-one

Consultation/Support from staff

Case Management within program

Verbal/written agreements

Capacity building skills training/coaching

Spoke with and/or met caregiver

Spoke with and/or met with other relevant adult supports (e.g. teachers, Probation Officers, primary care providers, etc.)

Other:

If 'Other' is checked, please specify:

RECOMMENDATIONS:

Recommendation 1

Recommendation 2

Recommendation 3

Presenting Issue/Pertinent Info (why are you referring this young person? What should we know?)

Does the person being referred have insurance? *

Yes

If 'Yes', what insurance?

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