COORDINATED SPECIALTY CARE (CSC)COORDINATED SPECIALTY CARE (CSC) WINGS PROGRAM ONLINE REFERRAL FORM Referrals will be responded to within 2 business days. If this is a life threatening emergency, Please call 911. Please check the appropriate box. Is this referral for a: Youth (under 18 years of age) Young Adult Self Referral Referral Source:Name of person filling out this form: Last NameRelationship to person referredIs the person filling out this referral also the parent/guardian of the referred person? Yes NoIf you are working with this person in a professional capacity, please name the agency or organization you are affiliated with:Phone number to reach you: Email address to reach you: Referral Information: Name of Person Referred: Last NameReferral’s Date of Birth: AgeReferral’s Race/EthnicityPrimary Language Spoken:Does this person need an interpreter?YesNoReferral’s Gender: - Select -MaleFemalenon-binaryReferral’s Pronouns: Is the referred person aware that you are making this referral? Yes NoReferral’s Home Address: Address Line 1Address Line 2CityCountyStateZip CodeReferral’s Phone:Email: School/ Current Grade Level: Referral’s Occupation: Is the youth / young adult a current participant in Comprehensive Community Services (CCS)? Yes No UnsureIf Yes, Name of Agency and Service Facilitator: Parent, Guardian, or Other Support InformationFirst NameLast NamePhone Number:EmailIs the parent/guardian aware that you are making this referral? Yes NoParent/Guardian primary language spoken:Does the parent/guardian require an interpreter?Reason for Referral:Describe the reason you are making a referral to the Wings program at this time:Any current diagnoses? To Support Possible WINGS Eligibility:1. Does the youth or young adult have any of the following symptoms? Hallucinations (auditory, sight, touch, smell, taste) Delusions (false beliefs that seem real to the person experiencing them) Difficulty telling reality from fantasy Suspiciousness, paranoid ideas, or uneasiness with others Unusual or overly intense ideas, strange feelings, or a lack of feelings Disruption in self-care Withdrawing socially and spending a lot more time alone2. Have these symptoms started within the last two years? Yes No Unsure2. Does the youth or young adult have a diagnosis of Psychosis, Schizophrenia, Schizoaffective Disorder, or Schizophreniform? Yes No UnsureReferral Information: NameLast NameDate of Birth: Race/EthnicityGender: - Select -MaleFemalenon-binaryPronouns: Primary Language:Do you require an interpreter? Yes NoHome Address: Address Line 1Address Line 2CityStateZip CodePhone:Email: School/ Current Grade Level: Occupation: Are you a current participant in Comprehensive Community Services (CCS)? Yes No UnsureIf Yes, Name of Agency and Service Facilitator: Reason for Self Referral:Please explain your reason(s) for your referral: Do you have any current diagnoses? To Support Possible WINGS Eligibility:Are you experiencing any of the following symptoms: Hallucinations (auditory, sight, touch, smell, taste) Delusions (false beliefs that seem real to the person experiencing them) Difficulty telling reality from fantasy Suspiciousness, paranoid ideas, or uneasiness with others Unusual or overly intense ideas, strange feelings, or a lack of feelings Disruption in self-care Withdrawing socially and spending a lot more time aloneHave these symptoms started within the last two years? Yes No UnsureDo you have a diagnosis of Psychosis, Schizophrenia, Schizoaffective Disorder, or Schizophreniform? Yes No UnsureThank you for your interest. Referrals cannot be accepted without the knowledge of the Parent/Guardian. Please email WingsCSC at info@WingsCSC to determine how to have this conversation with the family and how to encourage the family to complete a referral form. Thank you for your interest. Referrals cannot be accepted without the knowledge of the referred adult. Please email WingsCSC at info@WingsCSC to determine how to have this conversation with the individual and how to encourage them to complete a referral form. Submit