JACKSON COUNTY CROSS SYSTEM REVIEW REQUEST
Please do not include Personal or Protected Health Information (PHI)

To submit "CHILD/YOUTH SERVING SYSTEM BARRIER FORM" please go to the following link: https://www.surveymonkey.com/r/FNSXMWF

Question Title

* 1. Date:

Date / Time

Date

Question Title

* 2. PLEASE INDICATE REQUEST TYPE:

WRAPAROUND (FOR WRAPAROUND REQUEST ALL OF THE FOLLOWING CRITERIA SHOULD APPLY):
( ) Child/Youth aged 0-17
( ) Current Mental Health Assessment.
( ) Child/Youth is involved in 2 or more of the following systems and is experiencing complex needs (Child Welfare, Intellectual/Developmental Disabilities, Juvenile Justice, IEP or 504 at school, Mental Health, Oregon Youth Authority, Substance Use Disorder, Homeless, Complex Medical Conditions)
( ) Youth & Family agree to participate in the WRAP process
IF ALL WRAPAROUND CRITERIA IS MET, mark above and proceed to the next page.
IF ALL WRAPAROUND CRITERIA IS NOT MET AT THIS TIME, PLEASE COMPLETE THE COMPLEX STAFFING REQUEST (OPTION BELOW). DURING THE COMPLEX STAFFING MEETING, THE COMMITTEE WILL HELP YOU DETERMINE THE BEST NEXT STEPS, WHICH MAY INCLUDE A WRAPAROUND REFERRAL ONCE ALL THE CRITERIA ARE MET.

COMPLEX CASE REVIEW (STAFFING REQUEST) - COMPLEX CASE REVIEW PROVIDES RECOMMENDATIONS OF COMMUNITY RESOURCES AND/OR ADDITIONAL SERVICES AND SUPPORTS THAT MIGHT BE HELPFUL FOR YOUTH/FAMILY AND/OR REFERRING AGENT.

JACKSON COUNTY CROSS SYSTEM REVIEW REQUEST Please do not include Personal or Protected Health Information (PHI)

Question Title

* 1. Date:

Question Title

* 2. PLEASE INDICATE REQUEST TYPE:

JACKSON COUNTY CROSS SYSTEM REVIEW REQUEST
Please do not include Personal or Protected Health Information (PHI)