Referral Form

Screening/Referral Form

A Child's Haven
Program Overview

A Child’s Haven is a Medicaid Behavioral Health organization that treats children ages 6 months - 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!
Date*

MonthDayYear
Date
Referred By

First NameLast Name
Referral Agency
Referral Agency Phone Number*

Area CodePhone Number
E-mail*
General Information

At this time, initial assessment appointments will only be scheduled for children with an active and eligible Medicaid status.
Child's Name
Date of Birth

MonthDayYear
Date
Medicaid Number*
Assessment appointments will only be scheduled for children with an active and eligible Medicaid status.
Caregiver Information
Current Caregiver*

First NameLast Name
Relationship to Child
Caregiver Contact Email*
example@example.com
If non-custodial parent, do they have contact or visitation with child?

YesNo
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Does caregiver have legal custody?

YesNo
Primary language spoken in home
If primary language is not English, is caregiver fluent in English?

YesNo
Mother's Name (if different than caregiver)

First NameLast Name
Mother's Phone Number

Area CodePhone Number
Father's Name

First NameLast Name
Father's Phone Number

Area CodePhone Number
Have any siblings of the child attended ACH?

YesNo
Is there an open DSS / CPS case on the child / family?

YesNo
Case Worker Name
Phone Number

Area CodePhone Number
County / State
Additional Information
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
Has this child received an Autism diagnosis?

Autism diagnosis receivedNo diagnosis but Autism concern
Additional Medical Concerns
Premature Birth

YesNo
Number of weeks premature
Drug use during pregnancy

YesNo
Drugs
Tobacco use during pregnancy

YesNo
Packs/day
Alcohol use during pregnancy

YesNo
Type / Amount
Daycare History
Is the child currently enrolled in a child care center?

YesNo
Name of program / center (if applicable)
Has the child ever been discharged from a child care center because of behavior?

YesNo
Reason for Referral

Children enrolled in ACH must have documented behavioral challenges and/or social-emotional delays
Other Risk Factors:
Social/Emotional/ Behavioral Development Concerns (check all that apply)

WithdrawnOveractiveLacks initiativeDestructivePoor attention spanDefiantExhibits tantrumsHitsUpset by SeparationCommunication DelayNervousImpulsiveKicksUncooperativeBitesSad AffectUnaffectionateAngry AffectThrows Objects
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

General Information

Caregiver Information

Transportation Services

Medical History

Daycare History

Reason for Referral