CONFIDENTIAL

COST REFERRAL FORM

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

Is youth/member aware of referral? *
Gender *
Is caregiver aware of COST referral? *
REACH Member? *

Siblings at REACH? [Enter names here]

Is a translator needed? *
Strengths
check all that apply

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? *
Recent Academic/Vocational Changes? *
Academics/Vocational Concerns & Obstacles
Check all that apply

Emotional/Mental Health

Ongoing Emotional/Mental Health Concern? *
Recent Emotional/Mental Health Changes? *
Emotional/Mental Health Concerns & Obstacles
Check all that apply

Social

Ongoing Social Concern? *
Recent Social Changes? *
Social Concerns & Obstacles
Check all that apply

Health/Basic

Ongoing Health/Basic Concern? *
Recent Health/Basic Changes? *
Health/Basic Concerns & Obstacles
Check all that apply
Eating Concerns
Check all that apply
Basic Needs
Check all that apply
Health Issues
Check all that apply

PRIOR INTERVENTIONS AND RECOMMENDATIONS

Indicate at least 3 Interventions before making referrals

Interventions (what have you tried?)

RECOMMENDATIONS:

Does the person being referred have insurance? *