There is one universal referral form for Catholic Charities’ Care Coordination Services, which includes the Health Home Care Management Program and the Community Health Worker Program. Please use additional documents provided below as indicated.

Care Coordination Services Referral Form – Fillable

Care Coordination Services Referral Form – Non-fillable

Complete this form and email to carecoordination@ccwny.org

Remember to attached diagnostic eligibility documentation if available to facilitate the enrollment process. Complete the following forms if necessary:

SED Verification Form – Please complete for Youth with 1 SED diagnosis (no other diagnoses)

Complex Trauma Screening Form – Please complete for Youth with suspected Complex Trauma as a single qualifier (no other diagnoses)

• If a complete Complex Trauma Assessment has been completed by a licensed certified professional, please attach this document as well.
• If there is suspected Complex Trauma, complete the Complex Trauma Screening form and send it WITH the Referral Form.A complete Complex Trauma Assessment will need to be arranged and completed to determine if the youth is eligible under Complex Trauma as a single qualifier.

Complex Trauma as a single qualifier – If a youth is ONLY diagnosed with Complex Trauma, ALL the following forms must be completed prior to enrollment in the Care Management Program per DOH regulations.

• Complex Trauma Screening Form
• Complex Trauma Assessment
• Complex Trauma Referral Cover Sheet
• Complex Trauma Eligibility Determination
• Complex Trauma Assessment Guidelines