Child Referral Form for the MT Rural Telemental Health Program

This form is to be completed by the referrer (i.e., victim advocate, CPS worker, etc.) to refer a child for therapy via telemental health through the Montana Rural Telemental Health Program. Please verify with the child and caregiver that they are interested in therapy before making a referral. If information requested on this form has already been collected elsewhere, the referrer may reference those records to complete this form. For questions that cannot be answered via existing records, the referrer should ask the child and/or caregiver the question(s) directly and record their response.

A copy of this form will be submitted to the Children's Alliance of Montana's (CAM) Montana Rural Telemental Health Program, which will use it to identify a therapist. After identifying the therapist, CAM will connect the therapist and referrer for a conversation about the child. At that point, the referrer will discuss the information on this form and share any additional details that may be important for the therapist to know about the child, family, and situation.

Once you begin this form, you must complete it in one sitting. You will see a confirmation message at the end of the form once the form has been successfully submitted. If you do not see this message, your form has not been submitted. Please contact Jacole Douglas at jacole@childrensalliancemt.org if you have any questions while completing the referral form.