513-272-2800
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5050 Madison Road, Cincinnati, OH 45227

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Our Services
Our Organization
Our Results
Get Involved
Careers
News
- News & Resources
- Corridors
Contact Us

REFERRAL

Referring Information

Was permission from parent/guardian of the child received? (If no, you must obtain permission before submitting referral) *

Person Making Referral

Refer Phone

Referring Entity (Name of school, clinic, hospital, agency, etc.; if the parent/guardian is making the referral, enter "Self")

Requested Service(s)

Behavioral Health Counseling (ages 3-18) Day Treatment (grades PreK-12) Medical Management Services Autism Services The Children's Home Schools (grades K-12) Afterschool Virtual (grades 9-12) Alcohol and Drug Counseling

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

Child's Gender

Parent/Guardian Information

Parent/Guardian Name

Relationship to Child

Primary Phone

Secondary Phone

Address

City, State, Zip

Does the county have custody?

Insurance Information

Does the Child have Medicaid? (If yes, complete the Medicaid insurance information below)

Medicaid Number (MMIS) - 12 digits

Medicaid Member ID - 11 digits

Does the Child have Commercial Insurance? (If yes, complete the Commercial insurance information below)

Commercial Insurance Carrier

Policy Number

Group Number

Policy Holder Name

Policy Holder Relationship to Child

Symptoms/Behaviors

Check any symptoms or behaviors that apply to this child:

Crying excessively Angry outbursts; rage; tantrums Fighting Verbally abusive or aggressive Does not accept responsibility for behavior Poor peer relationships Depressed; sad; tearful Anxious; nervous; restless; fearful Death of a loved one; loss; separation Hyperactive; restless; cannot sit stil Irritable Limited range of emotions Lacks empathy

Hoarding or gorging food Stealing Short attention span; easily distracted Disruptive; attention seeking Low self-esteem; poor social skills Defiant; refuses to follow rules Impulsive; does not think about consequences Hostile; agitated; intimidating; aggressive No eye contact; unkempt; disheveled Lies; exaggerates; triangulates Sexually inappropriate behavior/focus Exaggerated startle response Persistent and unrealistic worry/fears

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?

Is there current concern regarding homicidal ideation or desire to seriously harm another person?

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.

Make a Gift

Our mission of transforming the lives of children and their families cannot be fulfilled without the generous support of individuals like you.

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VOLUNTEER WITH US

We offer various volunteer opportunities throughout the year for individuals and organizations. Projects such as landscaping and program supply drives are a great way to bond with fellow co-workers, church members or others while contributing to a worthy cause benefitting Cincinnati’s most vulnerable populations. For more information about volunteer opportunities, contact us at volunteer@tchcincy.org.

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CONTACT US

The Children's Home
5050 Madison Road
Cincinnati, OH 45227
(513) 272-2800