Name of person referring the youth
MM slash DD slash YYYY
Youth's name
MM slash DD slash YYYY
Is the youth receiving Special Education services?
Parent/guardian name
Does the youth have Medicaid coverage?
Youth's most current diagnosis
History of most recent treatment services
Inpatient or outpatient?
Does the youth demonstrate escalating problems of self-harm or assaultive behaviors as evidenced by
Suicidal ideations and/or threat to self or other?
Current self-harm behaviors?
Evidence of physical aggressions to self or others?
Please send all questions and referral information to: or call: 435-256-7500

A clinical decision cannot be made until collateral documentation is received. Collateral information can include, but is not limited to:
- Predisposition reports including a list of current and previous charges
- Current and past placement progress and discharge reports
- Recent psychological or psychiatric evaluations including diagnosis and full-scale IQ score
All information is handled securely and is not available to any third parties.