Intake Form Testing Ground Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Are you a person in the child's life looking for support or are you a medical provider completing a referral? *I am a parent or caregiverI am a medical providerName of person completing the form *FirstLastWhat is your relationship to the child/teen? *At what company or organization do you work? *Name of the child/teen you are referring *Name of the child/teen for whom you're seeking information *How old is the child/teen? *Please enter a number from 0 to 18.What is the current city of residence for the child you are referring? *Where do you currently live? *If your child or teen has insurance, what type of insurance coverage do they have? *AgileBlue Cross Blue ShieldGroup Health/Health PartnersPreferredOneMedicaUCareUnited Health GroupOther coverageMy child does not have insuranceAssessmentMy child acts impulsively or without concern for risk *Not at allSlightModerateSevereMy child repeats certain behaviors or activities *Not at allSlightModerateSevereMy child is having difficulty in school (in-person) *Not at allSlightModerateSevereMy child is having difficulty in school (digital/distanced learning) *Not at allSlightModerateSevereMy child’s mood shifts unexpectedly *Not at allSlightModerateSevereMy child has thoughts, fears, or worries that make it hard for them to function *Not at allSlightModerateSevereMy child has eating or body image concerns and this is a primary concern *Not at allSlightModerateSevereMy child engages in negative self-talk *Not at allSlightModerateSevereMy child experiences anger, irritability or rage *Not at allSlightModerateSevereMy child is displaying physical aggression (hitting, kicking, throwing things) *Not at allSlightModerateSevereHas your child witnessed or experienced a traumatic event? *YesNoIs your child engaging in any unsafe or risky behaviors? *YesNoI'm not sureWas there a significant loss in your child’s life, such as a death, transition or divorce? *YesNoHas a teacher or pediatrician asked your child to complete a behavioral, emotional or developmental assessment? *NoYes, but we have not completed itYes, we had my child take an evaluationAre you currently receiving other mental health or support services for this child?YesNoIf you have any other requests, information or concerns regarding your child, please share them in the box below.Please include any psych testing, types of therapy, or any specific clinician skills/traits/identities that would be most helpful for your child or teen.Please share any other pertinant information for the child you are referring:Please include any psych testing, types of therapy, or any specific clinician skills/traits/identities that would be most helpful for this child or teen.Contact InformationPhone number (initial contact will be via phone) *Please note: the official referral requires a phone call, but email is a great starting point if it is more comfortable for you, the parent or caretaker.May we leave a message for you on voicemail at this number? *YesNoAny communication with Washburn Center is private and protected under HIPPA guidelines and regulationsEmailWhat time is best for Washburn Center to reach out?MorningAfternoonEitherAny communication with Washburn Center is private and protected under HIPPA guidelines and regulationsHow did you hear about Washburn Center?GoogleSocial MediaFriendSchool CounselorDoctor or TherapistAdvertisementSomewhere elseIs there a program that you think would be a good fit for your child?I would like advice on where my child may get the best careCase managementCrisis stabilizationDay treatmentFamily focusedIntensive In-homeOutpatient individual therapyOutpatient family therapyOutreach programWARM (referrals via partner hospitals & clinics only) *I understand that I will need to fill out a referral form below and fax it to 612-871-1505 to complete this referralClick here to view and download Washburn Center's Authorization for Release of Information Submit
