Referral for Peer Support Services A.E.D. (Accept, Empower, and Determination) “Heal Your Past, Change Your Present, Create Your Future” Personal Information Youth Last Name * Youth First Name * Parent/Guardian Name * Address * Contact Number * Email Address * Youth Date of Birth * Insurance Company Youth Diagnosis CPT Code Insurance Number Group, Policy or I.D # Primary Physician’s Name Physician or Facility’s # Basic Mental Health History Does the family have a mental/behavioral health history? YesNo Was a CANS completed for this youth? YesNo Is the person diagnosed with IDD (Intellectual developmental disability) or Autism? YesNo Medications prescribed or administered? Family’s Journey: * Required SendΔ “Heal your Past, Change your Present, and Create your Future.” ~Bernadine Williams~
