Referring Information
Was permission from parent/guardian of the child received? (If no, you must obtain permission before submitting referral) *
Yes
No
Person Making Referral
Refer Phone
Referring Entity (Name of school, clinic, hospital, agency, etc.; if the parent/guardian is making the referral, enter "Self")
Supplemental Documents
An IEP and ETR are required for referrals to TCH Schools.
For referrals to behavioral health services, please submit available documents.
Documents can be emailed to referrals@tchcincy.org
Child Information
Child Name
Child Date of Birth
Child SSN
Child School
Child's School District
Child's Grade
Child's Race
African American
Asian/Pacific Islander
Caucasian
Multi-Racial
Native American
Other
Child's Gender
Parent/Guardian Information
Parent/Guardian Name
Relationship to Child
Primary Phone
Secondary Phone
Email
Address
City, State, Zip
Does the county have custody?
Yes
No
Insurance Information
Does the Child have Medicaid? (If yes, complete the Medicaid insurance information below)
Buckeye
Caresource
Molina
Paramount
United Healthcare
Other
No
Unknown
Medicaid Number (MMIS) - 12 digits
Medicaid Member ID - 11 digits
Does the Child have Commercial Insurance? (If yes, complete the Commercial insurance information below)
Yes
No
Unknown
Commercial Insurance Carrier
Policy Number
Group Number
Policy Holder Name
Policy Holder Relationship to Child
Symptoms/Behaviors
Suicidal/Homicidal Ideation
If yes to either of these questions, please call our intake office at 513-272-2800 for an immediate assessment.
Is there a current concern regarding suicidal ideation?
Yes
No
Is there current concern regarding homicidal ideation or desire to seriously harm another person?
Yes
No
Substance Abuse
Is there a current concern regarding substance abuse? If yes, please specify substance(s).
Description of Child's Problem
Please describe the child's problem and/or other concerns:
How did you hear about us?
Thank you for your referral to The Children's Home. Our staff will contact the family to begin the intake process.
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