Referral new – Children's Bureau of New Orleans

Step 1 of 2

Children’s Bureau of New Orleans’s crisis clinicians provides immediate support and stabilization for children and families in the aftermath of a traumatic incident or death.   These services are short term (typically 1 – 4 sessions). In addition to support and stabilization, clinicians will work with families to assess need for continued interventions, such as more intensive therapy.

A crisis response is available for a recent loss or traumatic event for anyone 5 – 24 years of age, and their family, in Orleans, Plaquemines, and St. Bernard Parishes.

What parish does the individual/family reside?   (Required)

Orleans

St Bernard

Plaquemines

Other

Please select the parish to continue

Children’s Bureau of New Orleans’ crisis intervention services are able to serve those from Orleans, St. Bernard, and Plaquemines Parishes only. For Jefferson Parish you may reach out to Mobile Crisis Services at 504-832-5123.

Who is making this request for crisis intervention services?(Required)

Parent / Legal Guardian (for my child/family)

Myself (I am 18 – 24 years old)

Other (community agency, school, etc).

Parent Requesting

Demographic Information:

Individual's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Age(Required)

Date of Birth(Required)

Gender(Required)

Male

Female

Other

Decline to Answer

Gender - other: please specify

Pronouns

Preferred Language for individual

Preferred Language for individual - other

please specify

School

Grade

Do they have Insurance / Medicaid?(Required)

Yes

Please enter insurance provider/MCO

Parent or Legal Guardian Contact Information:

Parent or Legal Guardian Name(Required)

First Last

Preferred Language for Parent or Legal Guardian

Preferred Language for Parent or Legal Guardian - other

please specify

Relationship to the individual(Required)

Parent or Legal Guardian Phone(Required)

Parent or Legal Guardian Email

Best way to contact Parent or Legal Guardian:(Required)

Phone

Text

Best time to contact Parent or Legal Guardian:

Is there any additional Guardian / Caregiver contact information to provide?(Required)

Yes

Additional Guardian / Caregiver Name

First Last

Additional Guardian / Caregiver Phone

Additional Guardian / Caregiver Email

Best way to contact the Additional Guardian / Caregiver:

Phone

Text

Best time to contact the additional Guardian / Caregiver:

Are any other agencies involved with the individual/family?(Required)

Yes

Please select all agencies involved with the individual/family

Other agency involved

Reason for Request:

Incident Type(Required)

Please check all that apply

Incident type: other(Required)

please specify

Please provide a brief description of the incident(s) experienced and the current impact you are experiencing.(Required)

Approximate time period of when most recent incident occurred:(Required)

Additional Comments:

if any additional household members were impacted, please include their names here

If this individual is in immediate crisis including but not limited to active suicidal or homicidal thoughts. Please reach out to MCRT (504-826-2675), send to the nearest emergency room, or call 911.

If you provided an e-mail address above, a copy of the completed form will be emailed to you for your records once you hit submit.

Requesting Myself

(18–24 years old)

Your Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Best way to contact you:(Required)

Phone

Text

Best time to contact you:

Date of Birth(Required)

Age(Required)

Gender(Required)

Male

Female

Other

Decline to Answer

Gender - other: please specify

Pronouns

Preferred Language

Preferred Language - other

please specify

Do you have Insurance / Medicaid?(Required)

Yes

Please enter insurance provider/MCO

Reason for Request:

Incident Type(Required)

Please check all that apply

Incident type: other(Required)

please specify

Approximate time period of when most recent incident occurred:(Required)

Please provide a brief description of the incident(s) experienced and the current impact you are experiencing.(Required)

Additional Comments:

if any additional household members were impacted, please include their names here

If you are in immediate crisis including but not limited to active suicidal or homicidal thoughts. Please reach out to MCRT (504-826-2675), go to the nearest emergency room, or call 911.

Once you hit submit, a copy of the completed form will be emailed to you for your records.

Other Requesting

Organization Contact Information:

Your Name(Required)

First Last

Organization Name(Required)

Phone(Required)

Email(Required)

Best way to contact you:(Required)

Phone

Text

Best time to contact you:

Type of Intervention:

Are you requesting crisis intervention services for an individual/family or a group/agency?(Required)

Individual / Family

Group / Agency

Other Requesting - Individual / Family

Is the individual you are requesting services for over 18?(Required)

Individual is under 18 years old

Individual is 18 years old or older

Other Requesting - Individual Under 18

Individual's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Age(Required)

Gender(Required)

Male

Female

Other

Decline to Answer

Gender - other: please specify

Pronouns

Preferred Language for individual

Preferred Language for individual - other

please specify

School

Grade

Do they have Insurance / Medicaid?(Required)

Yes

Unknown

Please enter insurance provider/MCO

Consent for referral(Required)

By checking here, you are confirming that the individual/guardian has consented to this request for crisis intervention services

Participation in crisis intervention services for individuals under 18 years of age requires consent from the legal guardian. Are you aware of any custody or guardianship concerns for the referred child?(Required)

Yes

Please explain any custody or guardianship concerns:(Required)

Parent or Legal Guardian Contact Information:

Parent or Legal Guardian Name(Required)

First Last

Preferred Language for Parent or Legal Guardian

Preferred Language for Parent or Legal Guardian - other

please specify

Relationship to the individual(Required)

Parent or Legal Guardian Phone(Required)

Parent or Legal Guardian Email

Best way to contact Parent or Legal Guardian:(Required)

Phone

Text

Best time to contact Parent or Legal Guardian:

Is there any additional Guardian / Caregiver contact information to provide?(Required)

Yes

Additional Guardian / Caregiver Name

First Last

Additional Guardian / Caregiver Phone

Additional Guardian / Caregiver Email

Best way to contact the Additional Guardian / Caregivern:

Phone

Text

Best time to contact the Additional Guardian / Caregiver:

Are you aware of any other agencies involved with the individual/family?(Required)

Yes

Please select all agencies involved with the individual/family

Other agency involved

Reason for Request:

Incident Type(Required)

Please check all that apply

Incident type: other(Required)

please specify

Please provide a brief description of the incident(s) experienced and the current impact the individual/family is experiencing at this time. Include information about impacts in their daily functioning, relationships, etc.(Required)

Approximate time period of when most recent incident occurred:(Required)

Mandated Reporting:

Does the reason for this request for crisis intervention services include a history of child abuse?(Required)

Yes

Please ensure that the incident has been reported to the appropriate authorities. If a report has not been made please report any immediate safety concerns, by calling: 1-855-4LA-KIDS (855-452-5437). Reports that do not require immediate attention may be completed online here.

Please indicate below how the necessary mandated reports of abuse and neglect related to this request for service have been made to the appropriate authorities.(Required)

Additional Comments:

if any additional household members were impacted, please include their names here

Once you hit submit, a copy of the completed form will be emailed to you for your records.

Other Requesting - Individual Over 18

Individual's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Individual's Phone(Required)

Individual's Email

Date of Birth(Required)

Age(Required)

Gender(Required)

Male

Female

Other

Decline to Answer

Gender - other: please specify

Pronouns

Preferred Language for individual

Preferred Language for individual - other

please specify

School

Grade

Do they have Insurance / Medicaid?(Required)

Yes

Unknown

Please enter insurance provider/MCO

Consent for referral(Required)

By checking here, you are confirming that the individual has consented to this request for crisis intervention services

Are you aware of any other agencies involved with the individual/family?(Required)

Yes

Please select all agencies involved with the individual/family

Other agency involved

Reason for Request:

Incident Type(Required)

Please check all that apply

Incident type: other(Required)

please specify

Approximate time period of when most recent trauma occurred:(Required)

Additional Comments:

if any additional household members were impacted, please include their names here

Once you hit submit, a copy of the completed form will be emailed to you for your records.

Other Requesting - Group / Agency

Reason for Request:

Incident Type(Required)

Please check all that apply

Incident type: other(Required)

please specify

Please provide a brief description of the incident(s) experienced and the current impact the group/organization is experiencing at this time. Include information about impacts in their daily functioning, relationships, etc.(Required)

Approximate time period of when most recent trauma occurred:(Required)

Additional Comments:

Once you hit submit, a copy of the completed form will be emailed to you for your records.

Crisis Intervention and Stabilization (LA BEST) Referral

If you need immediate assistance or care, call 911.

Parent Requesting

Demographic Information:

Parent or Legal Guardian Contact Information:

Reason for Request:

Requesting Myself

Reason for Request:

Other Requesting

Organization Contact Information:

Type of Intervention:

Other Requesting - Individual / Family

Other Requesting - Individual Under 18

Parent or Legal Guardian Contact Information:

Reason for Request:

Mandated Reporting:

Other Requesting - Individual Over 18

Reason for Request:

Other Requesting - Group / Agency

Reason for Request: