Referral Form

Screening/Referral Form

Contact Information for Referrals and Assessments: (phone) 864-298-0025 ext. 2024 (fax) 864-298-0045 (email) referrals@achildshaven.org
Program Overview

A Child’s Haven is a Medicaid Behavioral Health organization that treats children ages 6 months to 6 years with developmental delays as a result of limited resources, abuse, or neglect, and provides support and education for their families. Our core services include daily Therapeutic Childcare (hours of operation are 7am-1pm), and weekly Individual Therapy and Family Therapy. We are guided by our vision of children in our community are thriving with families that nurture their success!
Referral Date*

MonthDayYear
Date
Referral Agency or Relation to Child*
Referred By*

First NameLast Name
Is this a referral from Front Porch Housing?

Yes, this is a referral from Front Porch Housing
Referral Agency or Referring Individual's Phone Number*

Area CodePhone Number
Referring Agency or Referring Individual's E-mail*
Child Information

At this time, A Child's Haven only accepts children with eligible and active Medicaid benefits. SC Medicaid and the following Medicaid Care Plans are accepted: First Choice, Healthy Blue, Absolute Total Care, Molina, and Humana. If your child is not eligible for Medicaid or has private insurance, please call our Billing Department at 864-298-0025 ext. 2024 to discuss potential scholarship opportunities and other community support programs.
Child's Name*
Date of Birth*

MonthDayYear
Date
Child's Gender

FemaleMale
Medicaid Number*
Assessment appointments will only be scheduled for children with an active and eligible Medicaid status.
Child's Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caregiver Information

Please provide contact information for the child's legal guardian using their full legal first and last names as shown on their identification card.
Current Legal Guardian*

First NameLast Name
Relationship to Child*
Legal Guardian's Phone Number*

Area CodePhone Number
Legal Guardian Contact Email*
example@example.com
Primary language spoken in child's home
If primary language is not English, is caregiver fluent in English?

YesNo
If non-biological parent(s), do biological parent(s) have contact or visitation with child?

YesNo
Mother's Name (if different than legal guardian)

First NameLast Name
Mother's Phone Number

Area CodePhone Number
Mother's Home Address (if different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Father's Name (if different than legal guardian)

First NameLast Name
Father's Phone Number

Area CodePhone Number
Father's Home Address (if different than child's)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have any siblings of the child attended ACH?

YesNo
Has there been DSS/CPS case involvement with the child/family?

Current DSS/CPS InvolvementNo DSS/CPS InvolvementPrevious DSS/CPS Involvement
Current/Previous Case Worker Name
Caseworker Phone Number

Area CodePhone Number
Caseworker County / State
Additional information about current or previous DSS/CPS case(s):
Transportation Services

A Child's Haven has limited morning and afternoon transportation available on a critical needs basis. Critical needs are defined by but not limited to lack of transportation, homelessness, or caregiver employment obligations. Transportation is not guaranteed and needs are discussed during the initial assessment and enrollment process.
Is there a critical need for transportation for your household to participate in therapeutic childcare services?

YesNo
If yes, please explain:
If transportation is requested, please note what time of day transportation services are critical:

Morning (7am-9am, times vary based on location)Afternoon (1pm-3pm, times vary based on location)Both
If transportation is requested, please provide transportation request pick-up/drop-off address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical History
Primary Physician / Pediatrician Name

First NameLast Name
Location
Has the child been seen by a primary physician within the last year?

YesNo
Is the child receiving any of the following services?

Early InterventionOccupational TherapySpeech TherapyPhysical TherapyOther
Has this child received an Autism diagnosis?

Autism diagnosis receivedNo diagnosis but Autism concern
Premature Birth

YesNoUnknown
Number of weeks premature
Alcohol use during pregnancy

YesNoUnknown
Drug use during pregnancy

YesNoUnknown
Tobacco use during pregnancy

YesNoUnknown
Additional Medical Concerns:
Childcare and School History
Is the child currently enrolled in a childcare center or school?

YesNo
Name of program/school/center child is currently enrolled (if applicable)
How many hours per day does your child attend childcare/school?
Has the child ever been discharged from a childcare center or school because of behavior?

YesNo
Name of program/school/center child has been discharged from (if applicable)
Behavioral Documentation

A Child's Haven treats children with behavioral, social-emotional, and developmental delays.
Social/Emotional/Behavioral Development Concerns (check all that apply)

WithdrawnOveractiveLacks initiativeDestructivePoor attention spanDefiantExhibits tantrumsHitsUpset by SeparationCommunication DelayNervousImpulsiveKicksUncooperativeBitesSad AffectUnaffectionateAngry AffectThrows ObjectsOther
Housing

ShelterHomelessWith Relatives
Family Risk Factors

Criminal Domestic ViolenceIncarcerated ParentParental Mental Health Issues
Contact information for A Child’s Haven:
20 Martin Drive
Greenville, SC 29617
(phone) 864-298-0025
(fax) 864-298-0045
referrals@achildshaven.org
Should be Empty:

Screening/Referral Form

Program Overview

Child Information

Caregiver Information

Transportation Services

Medical History

Childcare and School History

Behavioral Documentation