CYSHCN Referral Form – County of Saratoga, New York

Referral Source Information

Date

Name

Phone Number

Agency or Facility (if any)

Referral Source

Other Referral Source

Reason for Referral

Specify Healthcare Need(s) or Concern(s)

Child's Information

Child's Name

Child's Date of Birth

Sex

Male Female Prefer not to answer

Child's Address

City

Zip Code

Race

White Asian Black Native American or Alaskan Hawaiian or Pacific Islander Prefer not to answer

Ethnicity

Hispanic Non-Hispanic Prefer not to answer

Preferred Language

Other Information

Parent/Guardian #1 Name

Parent/Guardian #1 Relation to Child

Mother Father Grandparent Foster Parent Other

Other, please specify

Parent/Guardian Home Phone Number

Parent/Guardian Cell Number

Parent/Guardian Email Address

This transmission is for referral to the Saratoga County Children & Youth with Special Healthcare Needs Program. By submitting this referral, it is understood that the information may be confidential or privileged and that Saratoga County will handle and protect all information per the requirements of all associated federal and state privacy laws.