LCCN Universal Referral Form

This LCCN Universal Referral Form is intended to facilitate referrals between entities serving 3-18 year olds.  You may recognize this as the form IHR has traditionally provided to entities wishing to make referrals for services at our community mental health center.  The LCCN is developing some services that may be helpful for children, adolescents, and families that may not necessarily have a diagnosable mental health disorder.  When a patient screens positive in the medical setting or is otherwise identified as at-risk, this form will be used to communicate this information to the schools and IHR (please include LCCN database form with screening results).

All are welcome to use this form.  If you are a medical provider, please fax this form to the Resource Link Care Coordinator (for children ages 6-18) or to the OSF Early Intervention Program (for children 0-5).  Others, please fax to the LCCN office 815-842-3849.  The referral will be reviewed by Tier II, III, & IV facilitator/liaisons and a decision made about “next steps.”  Generally speaking, services will be provided in an additive fashion with clients receiving screening and targeted intervention with individual therapy or more intensive family services added as indicated by our LCCN decision-tree.  Whenever possible, please fax a signed exchange of information form along with this referral form to facilitate open lines of communication.