The SPARC Network - Referral & Intake Form
Referral Code:
All fields in blue are required.
First Name:
Last Name:
Middle Name:
Suffix:
II
III
IV
Jr
Sr
Date Of Birth:
Gender:
Male
Female
Unknown
Street:
City:
State:
Zip:
Social Security #:
Insurance Name:
Insurance Id No:
Home Tel:
Bus Tel:
Cell Tel:
Maiden Name:
Nickname:
Marital Status:
Divorced
Married
Separated
Single
Unknown
Race:
American Indian or Alaska Native
Asian
Black or African American
Declined
Native Hawaiian or Other Pacific Islander
Other Race
White
Ethnicity:
Declined
Hispanic or Latino
Hispanic, Cuban
Hispanic, Mexican American
Hispanic, Other
Hispanic, Puerto Rican
Not Hispanic or Latino
Not Hispanic Origin
Unknown
Unreported
Guardian name (if under 18)
Guardian Relationship
Referred by (name):
Referral Source:
Adult MH Community Provider
Adult MH Res Provider
Cardinal Innovations LME
Child MH Community Provider
Child MH Res Provider
Community hospital psychiatric service
DJJ
DSS
Facility Based Crisis
First responder/clinical home provider
Hospital
Hospital emergency department
Justice system
Law enforcement
LME (STR, Crisis Line, Emerg. Resp. Unit)
MCM
Mobile Crisis Team
Other
Other/Unknown
Partners Behavioral Health LME/MCO
Primary care provider
School
Self
Self/Guardian
State ADATC
Referrer Tel:
Referrer other contact info:
Why Are You Here Today?:
Symptoms Checklist
Anxiety:
Yes
No
No Response
Depression:
Yes
No
No Response
Behavioral issues - aggression/injury/
destruction/taking risks, noncompliance:
Yes
No
No Response
School issues:
Yes
No
No Response
Employment issues:
Yes
No
No Response
Trouble sleeping:
Yes
No
No Response
Decrease in appetite:
Yes
No
No Response
Weight changes:
Yes
No
No Response
Physical illness:
Yes
No
No Response
Martial issues:
Yes
No
No Response
Parenting support
Yes
No
No Response
Adjusting to grief/loss/stressor
Yes
No
No Response
Legal issues
Yes
No
No Response
At Risk For Out Of Home Placement:
Yes
No
No Response
ADHD/ODD:
Yes
No
No Response
ADHD With Resistance To Treatment:
Yes
No
No Response
Disruptive Mood Dysregulation Disorder:
Yes
No
No Response
Psychosis:
Yes
No
No Response
Other:
If you weren't able to be seen here today,
what would you have done?:
Emergency room
No services
Mobile Crisis
Other
No Response
Have you been seen for services in the last 90 days?
Yes
No
No Response
If so, where:
Recommended Service(s):
Family Centered Therapy
Home Therapy Services
Outpatient Treatment
Recommended Service(s) Other:
File To Upload:
The SPARC Network can only receive complete referrals. A complete referral includes your information and the contact information for the parent or legal guardian (if applicable). Also, if the child is currently receiving MH services, the most current CCA and PCP must be submitted.