Referral Packet – please print and return the following forms to be considered for services.
- Application for Services
- Face Sheet for File
- Referral Application Checklist
- Behavior Skills Checklist
- Physical Form
- Authorization to Release and Obtain Information
- 3 Months Documentation/Progress Notes From Current Placement – RECENTLY ADDED
- The applicant shall be judged able to benefit from services provided.
- The applicant shall meet age requirements for programs for which they are applying.
- The applicant shall be able to obtain fee payment.
- The applicant shall not pose a serious threat to self or others.
- The applicant shall possess basic self-help skills (toileting, hygiene, dressing) to the best of their ability.
- The applicant shall not be medically unstable.
- No applicant will be denied services based on race, color, creed, national origin, age, disability, sex, marital, familial, or parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or status with regard to public assistance.
- Reasonable accommodations will be implemented when appropriate.
Service Acquisition Order of Acceptance
- A written or verbal referral must be made by a funding agency unless services will be privately paid.
- Application information will be reviewed by Concerned, Inc’s Application Review Committee.
- All potential applicants will have the opportunity to tour the facility and inquire about the services.
- The committee will base their acceptance decisions on the entrance criteria for the program applied for.
- Concerned, Inc. will accept applicants on a first-come, first-served basis.
- Upon acceptance for services, a current psychological evaluation and physical examination will be requested.
- All applicants will be will be notified by phone or letter of their acceptance or denial for services. Valid reasons will be given if an applicant is denied services.
- In the event that an applicant does not qualify for services, the committee will provide adequate referrals to other services.
- The organization does not currently maintain a waiting list. If the need for a waiting list should ever arise, the organization will continue to accept applicants in the order that the application for services is filed.
For more information, or if you have questions about how to refer someone to Concerned, Inc., please contact:
(712) 755-5834 (phone)
(712) 755-7775 (fax)
Click here to email Concerned, Inc.