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CCSI Referral Information Referral Date: Referral Source and Phone: Email: Child Data: First Name: Middle Initial: Last Name: D.O.B: Age: Gender: In Custody Of: Relationship to Child: Address: Phone: Note Best Times to Contact Family: Others in Home: Name: Relationship: How Long? School Information: Child’s School: School Phone: Grade: Contact Person: Please list any service providers involved with the family now or in the past. Please give approximate dates of service and include phone numbers if possible. Agency: Contact Person: Telephone: ---PAGE BREAK--- Is this child at risk of an out of home placement Yes No If yes, through what system: What type of placement: Please give a brief description of the presenting problem or the reason for referral (include your impression of presenting problem, classroom behavior, academic performance, social relationships and familial environment.) Please list any medical diagnosis and medications that any of the family members are taking or have been taking within the last year. What do you see as some of the priority needs or issues regarding this referral are (concrete, emotional, social, academic, and/or mental health)? Describe the level of family/caretaker (does family participate in appointments, do they seek you out between appointments). What specifically do you think CCSI can provide for this child and family? Please note any barriers to services or treatment this child or family may have transportation, non-attendance by family or child, financial difficulties, non- compliance to specific therapeutic instruction, etc.: Signature Phone Date Please fax or email this completed CCSI referral and the attached release to: Fax to: Chris Driscoll (607)-753-5124 Email to: [EMAIL REDACTED] CCSI RM 102, 60 Central Ave. Cortland, NY 13045