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COMPLETED BY THE ASSESSOR AND RETURNED TO THE HEALTHY KIDS PRIMARY CARE PROVIDER LISTED ABOVE  @  l   CITY @  l   STATE %@  l  $ ZIP CODE0 @  l @ 9. STREET ADDRESS? @0 @  l w P@   1. PRIMARY CARE PROVIDER'S NAMEo @ @  l x P  2. TELEPHONE NUMBERH @ %@  l y P $ 3. DATE OF SCREENINGI  @@ @ l z  A CITY  @ @ @ l {  A STATE @%@ @ l |  A$ ZIP CODE 0 @% 0 @@ @ l } @ A 4. STREET ADDRESS?-0/@(. l -@. 4. ASSESSOR'S NAMEB-/%@*. l -.$ 5. TELEPHONE NUMBERHP@p l P Male P@ l P Female  ~0 % 0 % 0 @%N p P.SECTION II. PRIMARY CARE PROVIDER INFORMATION -/@). l - . DATE @  l   Mental Health Assessor Q@@p l 0 Substance Abuse Assessor \$@ l $ Regional Support Network X @ l  Urgent   P@ l @ Regular   0%@@ l @A$ 10. REASON FOR REFERRALU@ @  0 %N @p p2SECTION III. PATIENT INTERPRETATION CERTIFICATION $&%@!% l $ %$ DATE$0&%%@&%@&!#7I certify that the above referral was explained to in   F F  F,Arial ("3I certify that the above referral was explained to (8in ">"B$"@"@$"`"@PATIENT OR PARENT/GUARDIAN`#####@$@ LANGUAGE!#@#`and executed in my presence.   /@p/$See reverse for instructions.    .@/.@/-0/ @0@  l  P@  :5. LIST THE MEDICATION(S) THE PATIENT IS CURRENTLY TAKING @%@  l  P $ ,6. LIST PHYSICAL CAUSES THAT WERE RULED OUT0@%@@ l @A$ E7. DESCRIBE PREVIOUS MENTAL HEALTH/SUBSTANCE ABUSE SERVICES RECEIVED'P( @" l '`(  Mental health -((@# l ( ( Substance abuse 9'P( 0@$ l '`( None; explain: /)0+@%@&) l )@)$ 2. INITIAL TREATMENT PLANV+@0-%@'+ l +P@+$ )3. EXPLAIN WHY IF NO SERVICES ARE NEEDED0 @ l @ 5. RACEpp@@0fHEALTHY KIDS EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) REFERRAL FOR MENTAL HEALTH/SUBSTANCE ABUSE ASSESSMENT   KL   0 2. SEX`P@ 8. REFERRAL TYPE:` p 9. REFERRED TO:6@ N RN@ P PP P .11. 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000FFFFFFFFFFFFC003F800780078007FFFFFFFFC003FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFB 000FFFFFFFFFFFFE003F800780078007FFFFFFFFC003FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFD 001FFFFFFFFFFFFE007F80078007800FFFFFFFFFC003FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFC 001FFFFFFFFFFFFF00FFC00FC00FC00FFFFFFFFFE007FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF 803FFFFFFFFFFFFF81FFE01FE01FE01FFFFFFFFFF00FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFD C07FFFFFFFFFFFFFFFFFF03FF03FF07FFFFFFFFFF81FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFB F0FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFD here restore vmrs vmr end % FreeHandDict %%EndDocument: _ ` ` dBlack`dBlack dBlackfHEALTHY KIDS EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) REFERRAL FOR MENTAL HEALTH/SUBSTANCE ABUSE ASSESSMENT   KL  .#dBlack./PdBlackDSHS 01-192(X) (REV. 07/94)Pd"BlackCell1mm"ddd@ ddl KP Pd aPd@Black1. PATIENT'S NAME#dBlackP @d4BlackSECTION I. PATIENT INFORMATIONd"BlackCell2 )i*ddd@ ddl KP Pe adBlack%3. PATIENT IDENTIFICATION CODE (PIC)#dBlackCell3 )i*ddd@ ddl KP Pfa#dBlack4. BIRTH DATEdBlackCell4 )i*ddd ddl KP PgdBlack6. PARENT'S/GUARDIAN'S NAMEdBlackCell6 0i*ddd ddl KP Pj dBlack7. RELATIONSHIP TO PATIENT#dBlackCell7 0i*ddd ddl KP Pk#dBlack8. TELEPHONE NUMBER%&@#dBlack%P&0 d4BlackjSECTION IV. COMPLETED BY THE ASSESSOR AND RETURNED TO THE HEALTHY KIDS PRIMARY CARE PROVIDER LISTED ABOVE "BlackCell5i*d@ ddl KP PadBlackCITY BlackCell8i*d@ ddl KP PadBlackSTATE #BlackCell9i*d@ ddl KP Pa#dBlackZIP CODE BlackCell106i*d@ ddl KP P adBlack9. STREET ADDRESS  @dBlackCell18 )i*ddd  ddl KP Pw dBlack 1. PRIMARY CARE PROVIDER'S NAME  @dBlackCell19(i*ddd  ddl KP Px  dBlack2. TELEPHONE NUMBER  @#dBlackCell20 $i* ddd  ddl KP Py  #dBlack3. DATE OF SCREENING @ BlackCell21i* d  ddl KP Pz P !dBlackCITY @ BlackCell22i* d  ddl KP P{ P !dBlackSTATE @ #BlackCell23i* d  ddl KP P| P !#dBlackZIP CODE @ #dBlack @ BlackCell24i* d  ddl KP P} P !dBlack4. STREET ADDRESS-.BlackCell11 0i*d- ddl KP P- -dBlack4. ASSESSOR'S NAME-.#dBlackCell12?i*ddd- ddl KP P--#dBlack5. TELEPHONE NUMBERPdBlackCell50 )Mddd@ ddl KP P`adBlack2. SEX`dBlackCell51 5MddP dl KP P `dBlackMale@dBlackCell52Mdd dl KP P @dBlackFemale #dBlack  #  #dBlack @P d4Black.SECTION II. PRIMARY CARE PROVIDER INFORMATION-."BlackCell49?TZd- ddl KP P--dBlackDATE 0@#dBlackCell13 )TZddd ddl KP P @#dBlack9. REFERRED TO:P @dBlackCell14 5TZdd  dl KP P` 0@dBlackMental Health AssessorP`dBlackCell15`TZddP dl KP P``0dBlackSubstance Abuse AssessorP#dBlackCell16`TZdd dl KP P`0#dBlackRegional Support NetworkP dBlackCell53`TZdd dl KP P`@dBlackUrgent  P dBlackCell37TZdd dl KP P`@ dBlackRegular  BlackCell389TZd ddl KP P dBlack.11. PHYSICIAN'S/PHYSICAL EXAMINER'S SIGNATURE@#dBlackCell35 o{ddd ddl KP PP !#dBlack10. REASON FOR REFERRALdBlack @#dBlackP @PdBlack2SECTION III. PATIENT INTERPRETATION CERTIFICATION$%#"BlackCell39-{!d$ ddl KP P$$#dBlackDATE$%#dBlack$%dBlack$%$%BlackCell40){"d$ ddl KP P$ $dBlackWITNESS/INTERPRETER'S SIGNATURE!0#p d.Black7 I certify that the above referral was explained to in   ! !"@dBlack! !"@!"@PdBlackPATIENT OR PARENT/GUARDIAN#>`#B `dBlack#@`#@ `#` #dJBlackLANGUAGE" #pdBlackand executed in my presence.  .P/p#dBlackSee reverse for instructions.  -.dBlack-.-.dBlack @d"BlackCell17HTb#ddd  ddl KP P dBlack:5. LIST THE MEDICATION(S) THE PATIENT IS CURRENTLY TAKING @#dBlackCell25HTb$ddd  ddl KP P  #dBlack,6. LIST PHYSICAL CAUSES THAT WERE RULED OUT@#dBlackCell26,Tb%ddd ddl KP PP !#dBlackE7. DESCRIBE PREVIOUS MENTAL HEALTH/SUBSTANCE ABUSE SERVICES RECEIVED@ 0dBlackCell339Tb&ddd ddl KP P  0dBlack8. REFERRAL TYPE&@(#dBlackCell27:Tb'ddd' ddl KP P&P '!#dBlack1. ASSESSMENT RECEIVED&'dBlackCell28YTb(dd dl KP P&'dBlack Mental health'(PdBlackCell41YTb)dd dl KP P'(pdBlackSubstance abuse&'dBlackCell42YTb*dd dl KP P&'dBlackNone; explain:(*#dBlackCell43RTb+ddd)@ ddl KP P( )a#dBlack2. INITIAL TREATMENT PLAN*-#dBlackCell44RTb,ddd+ ddl KP P* +#dBlack)3. EXPLAIN WHY IF NO SERVICES ARE NEEDEDdBlackCell29-Pf-ddd ddl KP P dBlack5. RACEF l  @U l   5. RACEw" A"@@@@ _ l@@ HX@@  @@ X    @@@@n n @@ X     2L!X@@  @@ e    @@@@ n @@ X  e  2L!6B >]~V,@@ @" mT2.2.mT2.2.2.2.222-2-2-2-2-2-2-2-2-2-2-2-2-2-2-2-2-2-2-2-2-2-2.2.2.2.2.2.2.2.2.2.2.2., propalis propalisN propalisH propalisB<E porpsila* porpsila6pellell26Cell33Cell27Cell28Cell41Cell42Cell43Cell44Cell29FFFFFFF FFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFFF9 FFFV"FFFE 3F807FF0FFF0FE1F9FF8FC3FEV"C003FFFE0F0FFFF0C3FFFFE1FF8003N*3Submit 78007o6XXjdVXXd'ʌS ?dFFFFE1FF3FF1 @(@ @q_(mT2+2+mT2+2+2+2+22+ propalis propalisN propalisH propalisB<E porpsila* porpsila6T`TArialtica T@= @8TT@1E FFFF8003FFE00_  R  4 HH   HH \ HH \ HH \ HH  HH . HH 1 HH 4 HH R HH  HH  HH  HH X HH L HH L HH I HH L HH I HH F HH F HH = HH @ HH . HH " HH F HH U HH  HH  HH  HH  HH @ HH C HH R HH  HH  HH  HH  HH  HH  HH  HH  HH x HH x HH x HH x HH u HH \ HH \ HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH h HH ^ HH a HH a HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH j HH j HH j HH j HH ^ HH v HH  HH  HH  HH  HH p HH j HH d HH m HH  HH  HH  HH  HH  HH  HH  ~HH ~ }~HH }~z |}HH |}z {|HH {|z z{HH z{z yzHH yzk xyHH xy\ wxHH wx\ vwHH vw\ uvHH uv\ tuHH tu\ stHH st\ rsHH rs\ qrHH qr\ pqHH pq\ opHH op\ noHH no\ mnHH mn\ lmHH lm\ klHH kl\ jkHH jk\ ijHH ijb hiHH hib ghHH ghq fgHH fgq efHH efq deHH dee cdHH cd bcHH bcX abHH ab `aHH `a _`HH _` ^_HH ^_ ]^HH ]^ \]HH \] [\HH [\ Z[HH Z[ YZHH YZd XYHH XY_ WXHH WXe VWHH VW\ UVHH UV\ TUHH TU STHH STw RSHH RS QRHH QR7 PQHH PQ OPHH OP NOHH NO MNHH MN LMHH LM KLHH KL JKHH JKt IJHH IJn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`o // () -(###) ###-#### ;-#####;#####-####@@X  @@N@@@@ @@@@@`܎4dNJL4`܎dT8TLT`^<`/|_T<Z``/ATT`/T"T`/'T`/TLA`/(T@/D\ATA@@ A@@@@ _ l@@ XD@@  @@ X  ( @@@@n n @@ X     Lr0- I@+$P FSECTION I. PATIENT INFORMATION 1. PATIENT'S NAME: The name of the patient being screened. 2. SEX: The sex of the patient being screened. 3. PATIENT IDENTIFICATION CODE (PIC): The state-assigned PIC number printed on the medical coupon. 4. BIRTH DATE: The birth date (month/day/year) of the patient being screened. 5. RACE: The patient's race. 6. PARENT'S/GUARDIAN'S NAME: The name of the patient's parent or legal guardian, if the patient is under 18 years of age. 7. RELATIONSHIP TO PATIENT: Mother, father, grandmother, legal guardian, etc. 8. TELEPHONE NUMBER: The telephone number of the patient, or parent/guardian if the patient is not the responsible party for authorizing the mental health and/or drug/alcohol referral and exchange of medical information. 9. STREET ADDRESS, CITY, STATE, AND ZIP CODE: The full address of the patient, or parent/guardian if the patient is not the responsible party for authorizing the mental health and/or drug/alcohol referral and exchange of medical information. SECTION II. PRIMARY CARE PROVIDER INFORMATION 1. PRIMARY CARE PROVIDER'S NAME: The name of the primary care provider. 2. TELEPHONE NUMBER: The telephone number of the primary care provider. 3. DATE OF SCREENING: The date (month/day/year) the Healthy Kids/EPSDT screen was done. 4. STREET ADDRESS, CITY, STATE, AND ZIP CODE: The full address of the primary care provider. 5. LIST THE MEDICATION(S) THE PATIENT IS CURRENTLY TAKING: List the medication you are aware that the patient is taking, including prescription, over-the-counter, and illegal drugs. 6. LIST PHYSICAL CAUSES THAT WERE RULED OUT: List the physical causes that were ruled out that could cause or aggravate the mental health and/or drug/alcohol symptoms that are being exhibited or suspected. 7. DESCRIBE PREVIOUS MENTAL HEALTH/SUBSTANCE ABUSE SERVICES RECEIVED: Describe any known previous mental health/substance abuse services that the patient has already received. 8. REFERRAL TYPE: Indicate whether this is a regular or urgent referral. REGULAR REFERRAL - A regular referral is indicated if, in your professional judgment, behaviors are present that need assessing such as: alcohol/substance abuse; family conflict; troubled peer relationships; school failure; somatic symptoms, abnormal behaviors, feelings, or thoughts; growth and development deficits; or social situation problems. URGENT REFERRAL - An urgent referral may be indicated if any of the following behaviors are present: victimization (untreated behaviors still evident); witness to death/substantial physical violence; at imminent risk of placement in restrictive setting; delusional, out of touch with reality; self-destructive behavior; destroying property; torturing animals; fire setting; sexually acting out; and suicidal behavior/ideation. Please contact the mental health provider, alcohol/substance abuse provider, or crisis response services immediately as appropriate. 9. REFERRED TO: Indicate where referred - mental health assessor, substance abuse assessor, and/or Regional Support Network. 10. REASON FOR REFERRAL: Describe the reason this patient is being referred for a mental health or alcohol/substance abuse assessment. 11. PHYSICIAN'S/PHYSICAL EXAMINER'S SIGNATURE: The signature of the medical provider performing the Healthy Kids/EPSDT medical screen. This may be a physician, Advance Registered Nurse Practitioner, or Physician's Assistant. SECTION III. PATIENT INTERPRETATION CERTIFICATION The language interpreter that explained this form and its' purpose to the patient or parent/guardian should fill in the patient or parent/guardian's name and in what language. This should be certified by the signature of the interpreter, and should be dated (month/day/year). SECTION IV. COMPLETED BY THE ASSESSOR AND RETURNED TO THE HEALTHY KIDS PRIMARY CARE PROVIDER LISTED ABOVE 1. ASSESSMENT RECEIVED: Indicate if a mental health or substance abuse assessment or no assessment was received by the patient. If no assessment was received, explain why. 2. INITIAL TREATMENT PLAN: Summarize the initial treatment plan of mental health and/or alcohol/substance abuse services you recommend the patient should receive. 3. EXPLAIN WHY IF NO SERVICES FOR THE PATIENT ARE NEEDED: If no mental health and/or alcohol/substance abuse services are recommended, explain why. 4. ASSESSOR'S NAME, DATE: Sign the mental health or alcohol/substance assessor's name and date of the assessment. 5. TELEPHONE NUMBER: The telephone number of the mental health or alcohol/substance abuse assessor.     9  g  o      v  `  INSTRUCTIONS   F . .@ DSHS 01-192 (REV. 07/1994) BACK_ Instructionsedical coupon. (g%4.(g7LBIRTH DATE: The birth date (month/day/year) of the patient being screened. (r%5.(r7RACE: The patient's race. (}%6.(}7xPARENT'S/GUARDIAN'S NAME: The name of the patient's parent or legal guardian, if the patient is under 18 years of age. (%7.(7LRELATIONSHIP TO PATIENT: Mother, father, grandmother, legal guardian, etc. (%8.(7wTELEPHONE NUMBER: The telephone number of the patient, or parent/guardian if the patient is not the responsible party (9dfor authorizing the mental health and/or drug/alcohol referral and exchange of medical information. (%9.(7vSTREET ADDRESS, CITY, STATE, AND ZIP CODE: The full address of the patient, or parent/guardian if the patient is not (9zthe responsible party for authorizing the mental health and/or drug/alcohol referral and exchange of medical information. (% (/SECTION II. PRIMARY CARE PROVIDER INFORMATION (%1.(7FPRIMARY CARE PROVIDER'S NAME: The name of the primary care provider. (%2.(7FTELEPHONE NUMBER: The telephone number of the primary care provider. (%3.(7VDATE OF SCREENING: The date (month/day/year) the Healthy Kids/EPSDT screen was done. (%4.(7[STREET ADDRESS, CITY, STATE, AND ZIP CODE: The full address of the primary care provider. (%5.(7oLIST THE MEDICATION(S) THE PATIENT IS CURRENTLY TAKING: List the medication you are aware that the patient is ( 9Etaking, including prescription, over-the-counter, and illegal drugs. (%6.(7lLIST PHYSICAL CAUSES THAT WERE RULED OUT: List the physical causes that were ruled out that could cause or (6 ("9`aggravate the mental health and/or drug/alcohol symptoms that are being exhibited or suspected. (-%7.(-7`DESCRIBE PREVIOUS MENTAL HEALTH/SUBSTANCE ABUSE SERVICES RECEIVED: Describe any known previous (89Nmental health/substance abuse services that the patient has already received. (C%8.(C7HREFERRAL TYPE: Indicate whether this is a regular or urgent referral. (N9wREGULAR REFERRAL - A regular referral is indicated if, in your professional judgement, behaviors are present that need (Y9}assessing such as: alcohol/substance abuse; family conflict; troubled peer relationships; school failure; somatic symptoms, (d/m abnormal behaviors, feelings, or thoughts; growth and development deficits; or social situation problems. (o9tURGENT REFERRAL - An urgent referral may be indicated if any of the following behaviors are present: victimization (z9(untreated behaviors still evident); witness to death/substantial physical violence; at imminent risk of placement in restrictive (/ setting; delusional, out of touch with reality; self-destructive behavior; destroying property; torturing animals; fire setting; (9ysexually acting out; and suicidal behavior/ideation. Please contact the mental health provider, alcohol/substance abuse (9Bprovider, or crisis response services immediately as appropriate. (%9.(7rREFERRED TO: Indicate where referred - mental health assessor, substance abuse assessor, and/or Regional Support (/ Network. (%x10. REASON FOR REFERRAL: Describe the reason this patient is being referred for a mental health or alcohol/substance ( (8abuse assessment. (%n11. PHYSICIAN'S/PHYSICAL EXAMINER'S SIGNATURE: The signature of the medical provider performing the Healthy (/ (9vKids/EPSDT medical screen. This may be a physician, Advance Registered Nurse Practitioner, or Physician's Assistant. (3SECTION III. PATIENT INTERPRETATION CERTIFICATION (The language interpreter that explained this form and its' purpose to the patient or parent/guardian should fill in the patient or ( parent/guardian's name and in what language. This should be certified by the signature of the interpreter, and should be dated ((month/day/year). (*^SECTION IV. COMPLETED BY THE ASSESSOR AND RETURNED TO THE HEALTHY KIDS PRIMARY CARE PROVIDER (5 LISTED ABOVE (K%1.(K7qASSESSMENT RECEIVED: Indicate if a mental health or substance abuse assessment or no assessment was received by (V/= the patient. If no assessment was received, explain why. (a%2.(a7wINITIAL TREATMENT PLAN: Summarize the initial treatment plan of mental health and/or alcohol/substance abuse services (l9*you recommend the patient should receive. (w%3.(w7kEXPLAIN WHY IF NO SERVICES FOR THE PATIENT ARE NEEDED: If no mental health and/or alcohol/substance abuse (9'services are recommended, explain why. (%4.(7pASSESSOR'S NAME, DATE: Sign the mental health or alcohol/substance assessor's name and date of the assessment. (%5.(7aTELEPHONE NUMBER: The telephone number of the mental health or alcohol/substance abuse assessor.`  INSTRUCTIONS   pF . . "DSHS 01-192(X) (REV. 07/1994) BACKpgt^*P Kg,j95ufe d:+kU wfz{}xv|PmyT PatientNamePatientIDNumberPatientBirthday GuardianNameGuardianPatientRelationshipPatientTelephonePrimaryProviderProviderTelephone ScreeningDate ProviderCity ProviderState ProviderZipProviderStreetAddress PatientCity PatientState PatientZipPatientStreetAddress AssessorNameAssessorTelephonePatientSexMalePatientSexFemaleDateReferralMentalHealthAssessorReferralSubstanceAbuseAssessorReferralRegionalSupportReferralUrgentReferralRegularReferralReasonPhysicianSignatureDateWitnessSignatureDate MedicationsPhysicalCausesMentalHealth_SubstanceAbuseMentalHealthAssessmentReceived SubstanceAbuseAssessmentReceivedNoAssessmentReceivedInitialTreatmentPlanNoServicesNeededExplanation PatientRace PatientName2 TranslationNoAssessmentReceivedExplanation  R  4 HH   HH \ HH \ HH \ HH  HH . HH 1 HH 4 HH R HH  HH  HH  HH X HH L HH L HH I HH L HH I HH F HH F HH = HH @ HH . HH " HH F HH U HH  HH  HH  HH  HH @ HH C HH R HH  HH  HH  HH  HH  HH  HH  HH  HH x HH x HH x HH x HH u HH \ HH \ HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH h HH ^ HH a HH a HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH j HH j HH j HH j HH ^ HH v HH  HH  HH  HH  HH p HH j HH d HH m HH  HH  HH  HH  HH  HH  HH  ~HH ~ }~HH }~z |}HH |}z {|HH {|z z{HH z{z yzHH yzk xyHH xy\ wxHH wx\ vwHH vw\ uvHH uv\ tuHH tu\ stHH st\ rsHH rs\ qrHH qr\ pqHH pq\ opHH op\ noHH no\ mnHH mn\ lmHH lm\ klHH kl\ jkHH jk\ ijHH ijb hiHH hib ghHH ghq fgHH fgq efHH efq deHH dee cdHH cd bcHH bcX abHH ab `aHH `a _`HH _` ^_HH ^_ ]^HH ]^ \]HH \] [\HH [\ Z[HH Z[ YZHH YZd XYHH XY_ WXHH WXe VWHH VW\ UVHH UV\ TUHH TU STHH STw RSHH RS QRHH QR7 PQHH PQ OPHH OP NOHH NO MNHH MN LMHH LM KLHH KL JKHH JKt IJHH IJn HIHH HI8 GHHH GH8 FGHH FG8 EFHH EF8 DEHH DE8 CDHH CD2 BCHH BC2 ABHH AB2 @AHH @A2 ?@HH ?@8 >?HH >?8 =>HH =>8 <=HH <=8 ;<HH ;<8 :;HH :;8 9:HH 9:8 89HH 898 78HH 788 67HH 678 56HH 568 45HH 458 34HH 348 23HH 238 12HH 12H 01HH 01H /0HH /0H ./HH ./H -.HH -.H ,-HH ,-H +,HH +,H *+HH *+H )*HH )*H ()HH ()H '(HH '(H &'HH &'H %&HH %&H $%HH $%H #$HH #$H "#HH "#H !"HH !"H !HH  !H  HH  H HH H HH H HH < HH < HH < HH < HH < HH < HH < HH < HH < HH < HH < HH 2 HH 2 HH 2 HH 2 HH  2 HH  2 HH  & HH  & HH  &  HH  & HH & HH & HH & HH & HH & HH & HH & HH  3Ur2 % @+ l  $ DATEw@0/%/ 0/P DSHS 01-192 (REV. 07/1994)M0p @, l @` 1. PATIENT'S NAMEM;@0%Np @SECTION I. PATIENT INFORMATION 0 @- l @ %3. PATIENT IDENTIFICATION CODE (PIC)y% @. l  $ 4. BIRTH DATE- 0 @/ l 0 6. PARENT'S/GUARDIAN'S NAME_0 @0 l @ 7. RELATIONSHIP TO PATIENT\% @1 l $ 8. TELEPHONE NUMBERH&0&%N&0p& jSECTION IV. COMPLETED BY THE ASSESSOR AND RETURNED TO THE HEALTHY KIDS PRIMARY CARE PROVIDER LISTED ABOVE   @2 l   CITY  @3 l   STATE % @4 l  $ ZIP CODE0  @5 l @ 9. STREET ADDRESS? @0  @6  l  P@   1. PRIMARY CARE PROVIDER'S NAMEo @  @7  l  P  2. TELEPHONE NUMBERH @ % @8  l  P $ 3. DATE OF SCREENINGI  @ @9 @ l   A CITY  @  @: @ l   A STATE @% @; @ l   A$ ZIP CODE 0 @% 0 @ @< @ l  @ A 4. STREET ADDRESS?-0/ @=. l -@. 4. ASSESSOR'S NAMEB-/% @>. l -.$ 5. TELEPHONE NUMBERXHP @?p l P Male XP @@ l P Female X ~ $  $ 0 @%N p P.SECTION II. PRIMARY CARE PROVIDER INFORMATION -/ @A. l - . DATE  @B  l   Mental Health Assessor Q@ @Cp l 0 Substance Abuse Assessor \$ @D l $ Regional Support Network X  @E l  Urgent   P @F l @ Regular   0% @G@ l @A$ 10. REASON FOR REFERRALU@ @  0 %N @p @2SECTION III. PATIENT INTERPRETATION CERTIFICATION $&% @H% l $ %$ DATE$0&%%@&%@&!#7I certify that the above referral was explained to in   F F  F,Arial ("3I certify that the above referral was explained to (8in ">"B$"@"@$"`"@PATIENT OR PARENT/GUARDIAN`#####@$@ LANGUAGE!#@#`and executed in my presence.   /@p/#See reverse for instructions.    .@/.@/-0/ @0 @I  l  P@  :5. LIST THE MEDICATION(S) THE PATIENT IS CURRENTLY TAKING @% @J  l  P $ ,6. LIST PHYSICAL CAUSES THAT WERE RULED OUT0@% @K@ l @A$ E7. DESCRIBE PREVIOUS MENTAL HEALTH/SUBSTANCE ABUSE SERVICES RECEIVED'P(  @L l '`(  Mental health -(( @M l ( ( Substance abuse 9'P( 0 @N l '`( None; explain: /)0+@% @O) l )@)$ 2. INITIAL TREATMENT PLANV+@0-% @P+ l +P@+$ )3. EXPLAIN WHY IF NO SERVICES ARE NEEDED0  @Q l @ 5. RACEpp@@0fHEALTHY KIDS EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) REFERRAL FOR MENTAL HEALTH/SUBSTANCE ABUSE ASSESSMENT   KL   0 2. SEX`P@ 8. REFERRAL TYPE:` p 9. REFERRED TO:6@ N RN@ P PP P .11. PHYSICIAN'S/PHYSICAL EXAMINER'S SIGNATURE$P% WITNESS/INTERPRETER'S SIGNATUREr&P'@ 1. ASSESSMENT RECEIVEDR "J$ @R  l  Title  "p#p @S" l  Title  & )$ @T" l  Title  /0pP RSN    XA@(@ @" -./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~(mT2۸2۱mT2۸2۸2۸2۸22<2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2ڸ2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2۸2 propalis propalisN propalisH propalisB<E porpsila* porpsila6pDataU}|{zyxwkjgfed& d& & d& e& f& g& j& k& & & & & w& x& y& z& {& |& }& & & @& @& & @& @& @& @& @& & & & & & @& @& @& & & & & &E;& @&;l@ 5?^i C@lj KxCm g,G1p[ j9U2~\ Q{ KEu n5VNx 9Mbw uPz V 1 ZR| f60_Z 4^ e %/NY wd.AT X j~ @S } 3:fBl +VAk 5_ 7a kUr3] 6`  )LRv {-)W Rwf8b z;e F{<+f T}>Gh pxv9c $|=:g cP~Dn Is HFp Hr 7mEo Gq 'y:d 7TvOy U $ MJ/t X { PatientNamePatientIDNumberPatientBirthday GuardianNameGuardianPatientRelationshipPatientTelephonePrimaryProviderProviderTelephone ScreeningDate ProviderCity ProviderState ProviderZipProviderStreetAddress PatientCity PatientState PatientZipPatientStreetAddress AssessorNameAssessorTelephonePatientSexMalePatientSexFemaleDateReferralMentalHealthAssessorReferralSubstanceAbuseAssessorReferralRegionalSupportReferralUrgentReferralRegularReferralReasonPhysicianSignatureDateWitnessSignatureDate MedicationsPhysicalCausesMentalHealth_SubstanceAbuseMentalHealthAssessmentReceived SubstanceAbuseAssessmentReceivedNoAssessmentReceivedInitialTreatmentPlanNoServicesNeededExplanation PatientRace PatientName2 TranslationNoAssessmentReceivedExplanationPhysicianSignatureDate1 PatientName3PatientIDNumber1PatientBirthday1 GuardianName1GuardianPatientRelationship1PatientTelephone1 PatientCity1 PatientState1 PatientZip1PatientStreetAddress1PrimaryProvider1ProviderTelephone1ScreeningDate1 ProviderCity1ProviderState1 ProviderZip1ProviderStreetAddress1 AssessorName1AssessorTelephone1PatientSexMale1PatientSexFemale1Date1ReferralMentalHealthAssessor1ReferralSubstanceAbuseAssessor1ReferralRegionalSupport1ReferralUrgent1ReferralRegular1ReferralReason1WitnessSignatureDate1 Medications1PhysicalCauses1MentalHealth_SubstanceAbuse1MentalHealthAssessmentReceived1!SubstanceAbuseAssessmentReceived1NoAssessmentReceived1InitialTreatmentPlan1NoServicesNeededExplanation1 PatientRace1 PatientName4 Translation1 NoAssessmentReceivedExplanation1PhysicianSignatureDate2 PatientName5PatientIDNumber2PatientBirthday2 GuardianName2GuardianPatientRelationship2PatientTelephone2 PatientCity2 PatientState2 PatientZip2PatientStreetAddress2PrimaryProvider2ProviderTelephone2ScreeningDate2 ProviderCity2ProviderState2 ProviderZip2ProviderStreetAddress2 AssessorName2AssessorTelephone2PatientSexMale2PatientSexFemale2Date2ReferralMentalHealthAssessor2ReferralSubstanceAbuseAssessor2ReferralRegionalSupport2ReferralUrgent2ReferralRegular2ReferralReason2WitnessSignatureDate2 Medications2PhysicalCauses2MentalHealth_SubstanceAbuse2MentalHealthAssessmentReceived2!SubstanceAbuseAssessmentReceived2NoAssessmentReceived2InitialTreatmentPlan2NoServicesNeededExplanation2 PatientRace2 PatientName6 Translation2 NoAssessmentReceivedExplanation2PhysicianSignatureDate3 PatientName7PatientIDNumber3PatientBirthday3 GuardianName3GuardianPatientRelationship3PatientTelephone3 PatientCity3 PatientState3 PatientZip3PatientStreetAddress3PrimaryProvider3ProviderTelephone3ScreeningDate3 ProviderCity3ProviderState3 ProviderZip3ProviderStreetAddress3 AssessorName3AssessorTelephone3PatientSexMale3PatientSexFemale3Date3ReferralMentalHealthAssessor3ReferralSubstanceAbuseAssessor3ReferralRegionalSupport3ReferralUrgent3ReferralRegular3ReferralReason3WitnessSignatureDate3 Medications3PhysicalCauses3MentalHealth_SubstanceAbuse3MentalHealthAssessmentReceived3!SubstanceAbuseAssessmentReceived3NoAssessmentReceived3InitialTreatmentPlan3NoServicesNeededExplanation3 PatientRace3 PatientName8 Translation3 NoAssessmentReceivedExplanation3Jsf& g& j& k& & & & & w& x& y& z& {& |& }& & & @& @& & @& @& @& @& @& & & & &\R  R  4 HH   HH \ HH \ HH \ HH  HH . HH 1 HH 4 HH R HH  HH  HH  HH X HH L HH L HH I HH L HH I HH F HH F HH = HH @ HH . HH " HH F HH U HH  HH  HH  HH  HH @ HH C HH R HH  HH  HH  HH  HH  HH  HH  HH  HH x HH x HH x HH x HH u HH \ HH \ HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH h HH ^ HH a HH a HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH j HH j HH j HH j HH ^ HH v HH  HH  HH  HH  HH p HH j HH d HH m HH  HH  HH  HH  HH  HH  HH  ~HH ~ }~HH }~z |}HH |}z {|HH {|z z{HH z{z yzHH yzk xyHH xy\ wxHH wx\ vwHH vw\ uvHH uv\ tuHH tu\ stHH st\ rsHH rs\ qrHH qr\ pqHH pq\ opHH op\ noHH no\ mnHH mn\ lmHH lm\ klHH kl\ jkHH jk\ ijHH ijb hiHH hib ghHH ghq fgHH fgq efHH efq deHH dee cdHH cd bcHH bcX abHH ab `aHH `a _`HH _` ^_HH ^_ ]^HH ]^ \]HH \] [\HH [\ Z[HH Z[ YZHH YZd XYHH XY_ WXHH WXe VWHH VW\ UVHH UV\ TUHH TU STHH STw RSHH RS QRHH QR7 PQHH PQ OPHH OP NOHH NO MNHH MN LMHH LM KLHH KL JKHH JKt IJHH IJn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a,  R  4 HH   HH \ HH \ HH \ HH  HH . HH 1 HH 4 HH R HH  HH  HH  HH X HH L HH L HH I HH L HH I HH F HH F HH = HH @ HH . HH " HH F HH U HH  HH  HH  HH  HH @ HH C HH R HH  HH  HH  HH  HH  HH  HH  HH  HH x HH x HH x HH x HH u HH \ HH \ HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH b HH h HH ^ HH a HH a HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH  HH j HH j HH j HH j HH ^ HH v HH  HH  HH  HH  HH p HH j HH d HH m HH  HH  HH  HH  HH  HH  HH  ~HH ~ }~HH }~z |}HH |}z {|HH {|z z{HH z{z yzHH yzk xyHH xy\ wxHH wx\ vwHH vw\ uvHH uv\ tuHH tu\ stHH st\ rsHH rs\ qrHH qr\ pqHH pq\ opHH op\ noHH no\ mnHH mn\ lmHH lm\ klHH kl\ jkHH jk\ ijHH ijb hiHH hib ghHH ghq fgHH fgq efHH efq deHH dee cdHH cd bcHH bcX abHH ab `aHH `a _`HH _` ^_HH ^_ ]^HH ]^ \]HH \] [\HH [\ Z[HH Z[ YZHH YZd XYHH XY_ WXHH WXe VWHH VW\ UVHH UV\ TUHH TU STHH STw RSHH RS QRHH QR7 PQHH PQ OPHH OP NOHH NO MNHH MN LMHH LM KLHH KL JKHH JKt IJHH IJn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l - $ DATEw@0/%/ 0/P DSHS 01-192 (REV. 07/1994)M0p @V l .@` 1. PATIENT'S NAMEM;@0%Np @SECTION I. PATIENT INFORMATION 0 @W l /@ %3. PATIENT IDENTIFICATION CODE (PIC)y% @X l 0 $ 4. BIRTH DATE- 0 @Y l 10 6. PARENT'S/GUARDIAN'S NAME_0 @Z l 2@ 7. RELATIONSHIP TO PATIENT\% @[ l 3$ 8. TELEPHONE NUMBERH&0&%N&0p& jSECTION IV. COMPLETED BY THE ASSESSOR AND RETURNED TO THE HEALTHY KIDS PRIMARY CARE PROVIDER LISTED ABOVE   @\ l 4  CITY  @] l 5  STATE % @^ l 6 $ ZIP CODE0  @_ l 7@ 9. STREET ADDRESS? @0  @`  l 8 P@   1. PRIMARY CARE PROVIDER'S NAMEo @  @a  l 9 P  2. TELEPHONE NUMBERH @ % @b  l : P $ 3. DATE OF SCREENINGI  @ @c @ l ;  A CITY  @  @d @ l <  A STATE @% @e @ l =  A$ ZIP CODE 0 @% 0 @ @f @ l > @ A 4. STREET ADDRESS?-0/ @g. l ?-@. 4. ASSESSOR'S NAMEB-/% @h. l @-.$ 5. TELEPHONE NUMBERXHP @ip l AP Male XP @j l BP Female X ~ $  $ 0 @%N p P.SECTION II. PRIMARY CARE PROVIDER INFORMATION -/ @k. l C- . DATE  @l  l D  Mental Health Assessor Q@ @mp l E0 Substance Abuse Assessor \$ @n l F$ Regional Support Network X  @o l G Urgent   P @p l H@ Regular   0% @q@ l I@A$ 10. REASON FOR REFERRALU@ @  0 %N @p @2SECTION III. PATIENT INTERPRETATION CERTIFICATION $&% @r% l J$ %$ DATE$0&%%@&%@&!#7I certify that the above referral was explained to in   F F  F,Arial ("3I certify that the above referral was explained to (8in ">"B$"@"@$"`"@PATIENT OR PARENT/GUARDIAN`#####@$@ LANGUAGE!#@#`and executed in my presence.   /@p/#See reverse for instructions.    .@/.@/-0/ @0 @s  l K P@  :5. LIST THE MEDICATION(S) THE PATIENT IS CURRENTLY TAKING @% @t  l L P $ ,6. LIST PHYSICAL CAUSES THAT WERE RULED OUT0@% @u@ l M@A$ E7. DESCRIBE PREVIOUS MENTAL HEALTH/SUBSTANCE ABUSE SERVICES RECEIVED'P(  @v l N'`(  Mental health -(( @w l O( ( Substance abuse 9'P( 0 @x l P'`( None; explain: /)0+@% @y) l Q)@)$ 2. INITIAL TREATMENT PLANV+@0-% @z+ l R+P@+$ )3. EXPLAIN WHY IF NO SERVICES ARE NEEDED0  @{ l S@ 5. RACEpp@@0fHEALTHY KIDS EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) REFERRAL FOR MENTAL HEALTH/SUBSTANCE ABUSE ASSESSMENT   KL   0 2. SEX`P@ 8. REFERRAL TYPE:` p 9. REFERRED TO:6@ N RN@ P PP P .11. PHYSICIAN'S/PHYSICAL EXAMINER'S SIGNATURE$P% WITNESS/INTERPRETER'S SIGNATUREr&P'@ 1. ASSESSMENT RECEIVEDR "J$ @|  l T Title  "p#p @}" l U Title  & )$ @~" l V Title  / 0p MENTAL HEALTH PROVIDER    3/92 % @ l W $ DATEw@0/%/ 0/P DSHS 01-192 (REV. 07/1994)M0p @ l X@` 1. PATIENT'S NAMEM;@0%Np @SECTION I. PATIENT INFORMATION 0 @ l Y@ %3. PATIENT IDENTIFICATION CODE (PIC)y% @ l Z $ 4. BIRTH DATE- 0 @ l [0 6. PARENT'S/GUARDIAN'S NAME_0 @ l \@ 7. RELATIONSHIP TO PATIENT\% @ l ]$ 8. TELEPHONE NUMBERH&0&%N&0p& jSECTION IV. COMPLETED BY THE ASSESSOR AND RETURNED TO THE HEALTHY KIDS PRIMARY CARE PROVIDER LISTED ABOVE   @ l ^  CITY  @ l _  STATE % @ l ` $ ZIP CODE0  @ l a@ 9. STREET ADDRESS? @0  @  l b P@   1. PRIMARY CARE PROVIDER'S NAMEo @  @  l c P  2. TELEPHONE NUMBERH @ % @  l d P $ 3. DATE OF SCREENINGI  @ @ @ l e  A CITY  @  @ @ l f  A STATE @% @ @ l g  A$ ZIP CODE 0 @% 0 @ @ @ l h @ A 4. STREET ADDRESS?-0/ @. l i-@. 4. ASSESSOR'S NAMEB-/% @. l j-.$ 5. TELEPHONE NUMBERXHP @p l kP Male XP @ l lP Female X ~ $  $ 0 @%N p P.SECTION II. PRIMARY CARE PROVIDER INFORMATION -/ @. l m- . DATE  @  l n  Mental Health Assessor Q@ @p l o0 Substance Abuse Assessor \$ @ l p$ Regional Support Network X  @ l q Urgent   P @ l r@ Regular   0% @@ l s@A$ 10. REASON FOR REFERRALU@ @  0 %N @p @2SECTION III. PATIENT INTERPRETATION CERTIFICATION $&% @% l t$ %$ DATE$0&%%@&%@&!#7I certify that the above referral was explained to in   F F  F,Arial ("3I certify that the above referral was explained to (8in ">"B$"@"@$"`"@PATIENT OR PARENT/GUARDIAN`#####@$@ LANGUAGE!#@#`and executed in my presence.   /@p/#See reverse for instructions.    .@/.@/-0/ @0 @  l u P@  :5. LIST THE MEDICATION(S) THE PATIENT IS CURRENTLY TAKING @% @  l v P $ ,6. LIST PHYSICAL CAUSES THAT WERE RULED OUT0@% @@ l w@A$ E7. DESCRIBE PREVIOUS MENTAL HEALTH/SUBSTANCE ABUSE SERVICES RECEIVED'P(  @ l x'`(  Mental health -(( @ l y( ( Substance abuse 9'P( 0 @ l z'`( None; explain: /)0+@% @) l {)@)$ 2. INITIAL TREATMENT PLANV+@0-% @+ l |+P@+$ )3. EXPLAIN WHY IF NO SERVICES ARE NEEDED0  @ l }@ 5. RACEpp@@0fHEALTHY KIDS EARLY AND PERIODIC SCREENING, DIAGNOSIS, AND TREATMENT (EPSDT) REFERRAL FOR MENTAL HEALTH/SUBSTANCE ABUSE ASSESSMENT   KL   0 2. SEX`P@ 8. REFERRAL TYPE:` p 9. REFERRED TO:6@ N RN@ P PP P .11. PHYSICIAN'S/PHYSICAL EXAMINER'S SIGNATURE$P% WITNESS/INTERPRETER'S SIGNATUREr&P'@ 1. ASSESSMENT RECEIVEDR "J$ @  l ~ Title  "p#p @" l  Title  & )$ @" l  Title  / P0p  ALCOHOL/SUBSTANCE ABUSE PROVIDER     2lv@(@ @" -./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~(mTmT2۸2< propalis propalisN propalisH propalisB<E porpsila* porpsila6pDataU}|{zyxwkjgfed& d& & d& e& f& g& j& k& & & & & w& x& y& z& {& |& }& & & @& @& & @& @& @& @& @& & & & & & @& @& @& & & & & & & & d& e& f& g& j& k& & & & & w& x& y& z& {& |& }& & & & & & & & & & & & & & & & & & & & & & .& & & & d& e& f& g& j& k& & & & & w& x& y& z& {& |& }& & & & & & & & & & & & & & & & & & & & & & X& & ArialaW̰TT@= T̐T`TTimes New Roman@= @8TT@Times New RomanArial