RSC Referral Form Instructions

To view additional details and examples while completing any of the forms, hover your mouse cursor over the dropdown list or open text field.

The form must be completed in the Adobe Acrobat Reader or Pro desktop program and NOT in the web browser version.

If the form opens in your web browser, click “Open in Desktop App” on the top right.

If you are unable to save the document by selecting File and Save As, select Print (also listed under File on the top left).

From the printer dropdown list, select “Microsoft Print to PDF” and click print at the bottom.

You will then be prompted to name the document and select the location of where you wish to save the document.

If you are interested in switching your settings to automatically open PDFs in your reader instead of your browser, follow the below step-by-step instructions for changing the settings in your PDF reader or software (for example, Adobe Acrobat Reader):

Open Acrobat Reader and select Menu > Preferences.
Click Internet in the left panel of the Preferences menu and then select Internet Settings.
Select the Programs tab.
Click Manage Add-Ons and choose Acrobat Reader in the list of add-ons.
Click Disable to ensure PDFs won’t be opened in a browser.

For more information specific to your browser, additional details and instructions can be located here: https://www.adobe.com/au/acrobat/hub/how-to/why-pdfs-open-in-browser.html#how-to-change-your-pdf-reader-settings

EBA-02jpeg Supporting Families logo 2017

Central: RSCCentral@ebanetwork.com
Northern: RSCNorth@ebanetwork.com
EBA Website: https://evidencebasedassociates.com/

EBA Provider Directory
http://vamap.evidencebasedassociates.com

Eastern: VAServices-Referrals@amikids.org
Southern: VAServices-Referrals@amikids.org
Western: VAServices-Referrals@amikids.org
AMIkids website: www.amikidsvirginia.org

AMIkids Provider Directory
http://www.amikids.org/amikids-virginia/vendordirectory

Referral Type	Select Initial Referral (new case/youth), New Service (youth is already referred to RSC and adding a new service(s), change in service, or prior service lapsed), or Extension (request for additional units or time for a youth currently receiving services) from the dropdown list.
Referral Date	Date the complete referral form and packet is sent To the RSC. This date will reflect the actual date BOTH the referral and packet is emailed to the RSC. Select a date from the calendar (dates in the past cannot be selected). Note, if the referral date is left blank, the age will not calculate.
Referring Region	Select the referring region of the youth from the dropdown list. This may be different than the location of the youth and will directly connect the youth's referral to an RSC agency and funding authorization.
Referring DJJ Unit	Select from the dropdown list. After selecting a region, the dropdown list will auto-populate with options specific to the selected region. To view all options, select “Choose an item” from the Referring Region dropdown. Choose the CSU responsible for oversight and payment verification. Select CAP if the youth is in direct care status and the referral is being made by the CAP staff. For parole youth, select the referring CSU.
Referring FIPS	Select from the dropdown list. After selecting a region and/or unit, the dropdown list will auto-populate with options specific to the selected region/unit. To view all options, select “Choose an item” from the Referring Region or Referring DJJ Unit dropdown. Select the FIPS code for the youth’s locality they are assigned to for supervision.
First and Last Name	Enter the youth's first name and last name to align with BADGE.
Juvenile #	Enter the youth's juvenile number to align with BADGE.
Date of Birth (DOB)	Enter the youth’s date of birth and the youth's age will auto-populate in years and months based on the Referral Date. Note, if the referral date is left blank, the age will not calculate.
Current Supervision Status	Select the youth’s current status as listed in BADGE from the dropdown.
Anticipated Supervision Status	Select the supervision status planned while the youth is in services. Generally, this is the same as the current status, unless the youth is direct care, and it is anticipated the youth will be on parole.
Youth's Current Location	List the youth's current physical location or residence at the time of referral in general terms (e.g., home, specific detention center, CPP, residential, etc.).
Expected Location for Services	List the location the service is expected to occur and special instructions, including contact information (e.g., home with family, at Blue Ridge CPP, in the community of the identified IL program, detained at RVJDC, contact Mr/Ms to coordinate).
Next Court Date	Select the youth’s next court date from the calendar (dates in the past cannot be selected).
Court Details	As applicable, describe the nature of the next court date (e.g., detention hearing, possible release from probation, etc.).
*Note: A Change Notification Form must be sent to the RSC to report a change in the youth's status or location.

Date of Current YASI	Select the date of most recent YASI or YASI Pre-Screen (should be within 90-days). If the YASI has not been completed, leave this box blank and add a reason in the next field.
If the YASI is not completed, indicate the reason	If a YASI Full Assessment or YASI Pre-Screen has not been completed, enter an explanation.
Overall Risk Level	Select from the dropdown to align with the current YASI Full Assessment or Pre-Screen.
Dynamic Needs-6 Level	Select from the dropdown to align with the current YASI.
Dynamic Protective Score	Select from the dropdown to align with the current YASI.
YASI Priority Domains 1, 2, & 3	Select each domain from their respective dropdown lists. Select priority items identified from the YASI and listed on the case plan, as applicable.
Indicate DSS Involvement	Select the most appropriate response from the dropdown list. This information provides context to help determine eligibility and special requirements guided by state DJJ and DSS MOUs/policies, as applicable.
Areas of Responsivity/Barriers	Check all potential barriers that may apply and elaborate in the open text box. If the youth or family's language creates a barrier, be sure to list the language spoken on the designated line.
Explain and elaborate areas of responsivity/barriers	Explain or elaborate on any barriers identified or other individual responsivity concerns to include motivation, readiness to change, developmental delays, language, transportation, phone, or internet barriers, etc.

Medicaid Status	Select the most appropriate response.
CSA Eligibility Status	Select the youth’s current eligibility status from the dropdown.
Current CSA/FAPT Involvement	Select the youth’s current CSA/FAPT involvement status from the dropdown.
Other Funding Available	Select other funding sources available to the youth and family from the dropdown lists, as applicable.
Explain other funding sources utilized, available, explored, and/or ruled out	Explain additional funding sources utilized or attempts to access other funding options. If the youth is involved with CSA, please indicate the service(s) provided and details.
Current Services	List all current service(s), start dates, provider name(s), contact information, funding source(s), and progress. Explain the effectiveness of the service(s) or current outcomes (e.g., service is effective, not yet proven effective in meeting the youth's needs, incomplete, or additional supports have been identified).
Prior Services	List all prior service(s), start and end dates, provider name(s), contact information, funding source(s), and progress. Explain the effectiveness of the service or outcome (e.g., service was successful, unsuccessful in meeting the youth's needs, incomplete, or additional supports were identified).

Requested Assessment/Evaluation Type	Select the appropriate sub-category.
What questions need to be answered during the assessment/evaluation?	Explain the purpose and goals. Describe the WHY? What questions need to be answered? For example, determine a clear diagnosis, clarify symptoms, coping skills, personality, recommend specific interventions/modalities, identify interventions to increase youth resilience, etc.
Is the assessment/evaluation court ordered?	If the referral is for an assessment or evaluation, select Yes or No.
Report and recommendations needed by	Select the date the report is needed back to the CSU to allow for pre-court filing and/or treatment planning purposes. This is likely different than the next court date (dates in the past cannot be selected).
Next Court Date	If the assessment/evaluation is court ordered, select the next court date (dates in the past cannot be selected).
Requested Provider	Type in the provider’s name if a specific provider is being requested; otherwise leave blank.
Remember, an assessment/evaluation does not provide treatment. In some cases, the youth may need a service immediately based on DJJ's assessment, youth acuity, or volatility.

Requested Sub-Category	Select from the drop-down list. Select unknown if additional guidance is needed or other if the requested service is not listed.
Service	Select from the drop-down list or type the requested service name. The list will auto-populate based on the selected sub-category. Select unknown if additional guidance is needed or if other was selected as the sub-category, type in the name of the requested service.
Dosage	List requested dosage to include recommended frequency and duration (e.g., 5 hours per week, once, twice per week, daily until completed, 30 days). For residential and independent living programs, include the anticipated length of stay (e.g., 9 to 12 months).
Provider	List the requested provider, if a specific provider is being requested. Refer to the appropriate RSC website (listed at the bottom of the form) for a full list of providers available in each region.
Primary Target Need Area for Requested Service	Select the YASI priority item identified on the case plan or as identified through an assessment that relates to each specific requested service.
Requested Start Date	Select the date you are requesting this specific service to begin (dates in the past cannot be selected). Services requested with complete referral packets may begin 10 days after the referral. *Please take into account when the family and youth expect the service(s) to begin.
If the youth is currently detained or in direct care, are services requested to begin prior to the youth's release to the community?	Select an item from the list if requesting a service to begin prior to the youth's release from a direct care setting. detention facility, CPP, residential setting, or group home.
Are pre-engagement activities being requested?	Select an item if the service is requested to begin pre-release. Pre-engagement activities may include introductory meetings, orientation, etc.
Provide a detailed rationale and goals for the specific service:
Summarize how the requested service addresses the identified criminogenic needs and priorities identified by the YASI Assessment and Behavioral Analysis. Provide a rationale for the service type, dosage (including frequency and length of services), and if a specific provider is being requested. Include recommendations from current placement and treatment bodies (e.g., staffing, treatment team, CCRC). For extension requests, provide a summary of the progress, the reason for an extension, anticipated discharge date, specific targets to be addressed, and outcomes to be met if services continue. For IL Programs, explain why the youth cannot return home and summarize other placement options pursued or exhausted (e.g., relatives, other adults, DSS, DRS). Indicate where the youth will live following the program, the back-up plan if funding or bed space is not available, and how the youth’s educational needs will be met while in the program.
Add an additional service request page	Click this button to add an additional service request page if needed. There is a limit of one additional page. If the number of services being requested exceeds this page limit, please contact the RSC. Click the button at the bottom of the added service request page to remove the additional page.

Commitment Date	Select the date the youth was committed to DJJ.
Anticipated Direct Care Release Date	Select the anticipated date the youth is expected to stepdown to parole (dates in the past cannot be selected).
Targeted Parole Release Date	Select the youth’s targeted parole release date (dates in the past cannot be selected).
Does the youth have a valid VA ID?	Select youth's valid Virginia identification status from the list.
MHSTP Status	Select the youth's MHSTP status from the list.
Educational Status	Select the current education status of the youth from the list.
List additional direct care or parole release details	Add additional details as needed (e.g., re-entry meeting, CCRC dates, next steps, etc.). Indicate if the youth will need approval from CCRC, to complete aspects of treatment, or receive approval from the Director or the courts.
List potential opportunities to engage with the DSP prior to release	Add additional details as needed (e.g., introductory or planning meetings, etc.). Indicate if such opportunities are in-person, virtual, or telehealth.
Explain the youth’s adjustment to current placement and recent behaviors	Explain the youth’s adjustment to current placement (e.g., JCC, CPP, CAP) to include behaviors, engagement in treatment, progress, incidents, family engagement, etc.
Provide details about the youth’s involvement in educational and vocational programs, including certifications	Explain the youth's involvement in educational and vocational programs in their current placement.
Sex Offender Registry Status (indicate registration status, last date of registration, and any special conditions)	Explain if the youth is on the registry or will be required to register.
Specific instructions for the proposed residential provider or IL program	Provide important details that need to be considered for the youth to be successful in a residential placement (e.g., security level, treatment required, youth needs to be placed in a sex offender unit).
*Note: A Change Notification Form must be sent to the RSC to report a change in the youth's PO, status, or location.

Referring Staff Name	List the name of the referring staff completing the request to include the CAP, Probation, or Parole Officer.
Referring Staff Title	Title/role of staff completing the referral request (e.g., CAP, Probation, Parole Officer, etc.).
Referring Staff Email Address	Email address of the referring staff.
Referring Staff Phone Number	List the referring staff's direct phone number.
Supervisor's Name	List the supervisor's name that reviewed the referral with the referring staff.
Supervisor's Title	Title/role of supervisor that reviewed the referral with the referring staff.
Supervisor's Email Address	Email address of supervisor.
Supervisor's Phone Number	List the supervisor’s direct phone number.
Other Staff Name(s)	List other related contacts here, as applicable. For example, if in direct care status, include the name of the community-based PO. If completed by the PO requesting pre-release services, then include the CAP or CPP Counselor.
Other Staff's Email Address	Email address of other related staff.
Other Staff's Phone Number	List the direct phone number for other related staff.

Documents to attach when emailing the completed PDF referral form to the assigned RSC company:
For all referrals, the current:	For all Probation, Parole, and Direct Care referrals:
BADGE Face Sheet Ensure information is accurate and matches the referral form information.	*YASI Behavioral Analysis (ABCD) and* YASI Narrative**
Release of Information Make sure all appropriate boxes are checked or the release cannot be accepted.	Social History
YASI Screen or Assessment (Wheel) Current and most recent; within 90-days.	Case Plan The case plan is required for most services, as it outlines the requested targeted areas identified by DJJ.
For all GPS/EM referrals: GPS Referral Guidelines Form
Additional items attached (check accompanying boxes and attach additional pages as needed):
BADGE Offense History	Useful for direct care placements or referrals to residential/IL programs.
Court Order	Needed for court ordered assessments/evaluations. All assessments/evaluations (and services) need prior approval from the RSC company, even if ordered by the court; funding is not required to be authorized by the RSC company. Remember, some assessments/evaluations can also be obtained through insurance, FAPT, or the need may be met without a formal assessment/evaluation.
Intake History/Police Reports (for assessments/evaluations)	Especially important and needed for psycho-sexual evaluations.
Prior Assessments (e.g., CANS)	Prior Screenings (e.g., MAYSI, SEAS, SASSI)
JCC Progress Reports	MHSTP: Needed for youth being released on parole.
IEP	Other Relevant Documentation: May include a safety plan, relapse prevention plan, or other reports.
Send the referral and supporting documents to:
This section includes information for both RSC companies. Email the completed PDF referral form along with any necessary attachments to the email address listed for the referring region. Links to resources for both companies are also provided (e.g., access to Release of Information forms, service descriptions, etc.). Each RSC company’s Provider Directory is also linked; these directories can be used to locate services and providers available in specific regions and localities.

*The referral form is a brief overview of the youth and service(s) as requested from the referring DJJ staff member, but does not reflect the final service(s) by the RSC company. Please refer to the approved service authorization (POSO) issued by the RSC company for documentation on the authorized service(s) and dosage.

The Regional Service Coordination Company Notes section is intended for internal use only by the RSC company.

Resetting/Clearing the Form

Click this button to reset the form and clear all text that has been entered, all dropdown selections, and all boxes checked.

RSC Model Referral Form Instructions

General Notes and Guidance

Youth Information

Assessment of Risk, Needs, & Responsivity

Funding Information and Other Services

Request for Assessments and Evaluations

Requested Services

Direct Care, Parole, Residential, and/or IL

Referring Staff and Related DJJ Contacts

Supervisor Review and Approval

Other Notes & General Comments

Required Attachments

Provider Notes and Instructions