CADC Therapeutic Consultations Referral

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please complete this form to request behavior support services through Creative Approach Development Center. Completing this referral form initiates the request process but does not guarantee that services will be provided. Please note that there is currently a waitlist for new services, and we anticipate that new services will begin in May 2025.

Individual's Initials *

Individual's Age *

Is the individual a DD waiver recipient? *

Yes

County Individual lives in *

Support Coordinator's name, email address, and phone number

Does this person have a legal guardian? *

Yes

If yes, please provide the legal guardian's name, email address, and phone number.

Preferred method of services (check all that apply) *

Virtual only

In-person at individual's home only

In-person at the CADC Office only

Blended (a mix of formats)

Required

Does this person require communication or any other accommodations to actively participate in services? (speech device, larger print materials, interpreter, etc.) *

Yes

If yes, which supports?

Has the individual worked with a Behavior Specialist before? *

Yes

Not sure

If the individual has, please provide the name of the organization services were with and why services ended.

Which types of behaviors does the individual engage in? (Check all that apply) *

Emotional Outbursts

Physical Aggression

Property Destruction

Eloping/Wandering

Self-harm

Suicidal Ideation/Suicidal Attempts

Stealing

Inappropriate Sexual Behaviors

Inappropriate Boundaries with Others (shares too much info, trusts strangers too quickly, etc.)

Excessive use of electronics

Impulsive Spending

Lack of Self-Care (taking showers, brushing teeth, etc.)

Excessive Eating

Extreme Lying

Excessive Refusal to Follow Directions (including taking meds)

Other

Required

If other please describe the behavior

Does this person engage in suicidal ideation? *

Yes

I am not sure

Is this person at risk of losing placement? *

Yes

I am not sure

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of Creative Approach Development Center, LLC.

Does this form look suspicious? Report

Forms