There is one universal referral form for Catholic Charities’ Care Coordination Services, which includes the Youth Health Home Care Management Program and the Community Health Worker Program. Please use additional documents provided below as indicated.
Complete this form and email to [email protected]
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)
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.