Wall Therapeutic Solutions ABA and Therapeutic Consultation in VA

Therapeutic Consultation Service Referral Form

1. Please Indicate the Therapeutic Consultation Service Interested In:

Behavior

Speech

Psychological

Recreation Therapy

Are you interested in participating in sessions remotely through telehealth?

Yes

2. Individual Being Referred for Services

First Name

Last Name

Date Of Birth

SSN

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

Guardian:

Phone/Mobile

Guardian Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Relationship:

Primary Language of Individual

Primary Language of Legal Guardian

3. Individual Making Referral

Individual Making Referral

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

4. Residential Service Provider (If Applicable)

Service Provider (Agency/Name)

Parent Provider?

Yes

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

5. Service Funding Source and Services Requested: Waiver

Requested Services

Therapeutic Behavior Consultation (Medicaid Waiver - FIS and CL only)

Behavior Consultation (Alternate funding source)

Support Coordinator

CSB

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Phone/Mobile

ISP DATES

PRC Dates

6. Diagnoses and Other Services

Diagnosis (please select all that apply)

F84.0: Autism

F70: Mild Intellectual Disability

F71: Moderate Intellectual Disability

F72: Severe Intellectual Disability

F73: Profound Intellectual Disability

F79: Unspecified Intellectual Disability

Other Diagnoses

7. ISP Aligned Shared Outcomes that Therapeutic Consultation services can address.

Shared Outcome #

Description of Outcome

Shared Outcome #

Description of Outcome

Shared Outcome #

Description of Outcome

Behavioral

8. Describe the Interfering Behaviors (if applicable)

Interfering Behavior(s)

Describe the interfering behavior(s)

Where does the behavior typically occur?

When does the behavior typically occur?

Severity

Frequency

Interfering Behavior(s)

Describe the interfering behavior(s)

Where does the behavior typically occur?

When does the behavior typically occur?

Severity

Frequency

Interfering Behavior(s)

Describe the interfering behavior(s)

Where does the behavior typically occur?

When does the behavior typically occur?

Severity

Frequency

Interfering Behavior(s)

Describe the interfering behavior(s)

Where does the behavior typically occur?

When does the behavior typically occur?

Severity

Frequency

Speech/Language

9. Please Indicate and Describe Communication Concerns

Communication Concern

Non-verbal or limited functional communication and pragmatic language

nintelligible or echolalic speech

Impairment in receptive

Where is your primary care doctor located ?

Phone Number of primary care doctor:

Psychological

10. Please Describe Psychological Symptoms and/or Concerns

Recreation Therapy

11. Please List domains/areas you feel recreation therapy may benefit this individual:

Yes

Please list current recreational activities the individual participates in or has interest in participating in in the future:

Other

13. Other Information:

14. Preferred Items, Activities, and Environments:

Aversive Items, Activities, and Environments:

15. Current Residential, Educational, Mental Health, Skill Building, Community Engagement, Leisure, and Job Related Services

Service

Phone/Mobile

Organization Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Contact Name

16. Current Medications - may also attach as document to the end of this referral form.

Name

Purpose

Dosage

Name

Purpose

Dosage

Name

Purpose

Dosage

17. Current Schedule

Dropdown

Monday

Tuesday

Wednesday

Thursday

Dropdown

Friday

Saturday

Sunday

Referring Source Signature

First Name

Last Name

Date / Time

Clinician- No other signatures required but please ensure that all stakeholders are aware of the referral, requirements, and have had all questions answered prior to submitting authorization requests.

Date of Initial Staff Contact with Referring Source

Please attach any documentation here:

Choose File

Date of Initial Staff Contact with Referring Source

Reason for Referral:

Results of Initial Contact:

Intake for Services

Placed on Waitlist

Referred Out to Other Provider(s)

If Referred to Other Provider(s), Please List Those Provider(s) Here: