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How can you make a referral?
- Contact your local Community Developmental Disabilities Organization (CDDO).
To find out which CDDO serves your community, find your county on the map.
For a list of the CDDOs and their phone numbers
click
here.
- Ask your CDDO for the SMRH Service Request Form, or
access the Request Form in .PDF format. You will need the free
Adobe
Acrobat Reader to view/print the file. For Outpatient Services,
access the Request Form in .PDF format and
mail it to the address listed below.
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Before DDT&TS Outreach Services can be conducted, documentation of a
developmental disability must be provided along with the application
materials.
You must contact the CDDO and have the referred person determined
eligible for developmental disabilities services before DDT&TS
Inpatient Services can be provided! |
- Complete the 2-page SMRH Service Request Form.
- If you need assistance completing the SMRH Service Request Form contact your
local CDDO.
- The SMRH form will need to be submitted to:
Karen Van Leeuwen, Director of Social Work
Parsons State Hospital & Training Center
P.O. Box 738
Parsons, KS 67357
Phone: (800)362-0390, Ext. 1788
FAX: (620)423-0419
For Outreach Services the completed request form may be submitted to
directly Karen Van Leeuwen, at Parsons State Hospital or through the CDDO. You can
receive a Request Form from your CDDO or
access the Request Form in .PDF format and
print a copy yourself.
For Inpatient Services your request must be made by submitting the
completed form to the CDDO. You can receive a Request Form from your CDDO or
access the Request Form in .PDF format and print a copy yourself. The CDDO will make the referral to DDT&TS for Inpatient Services.
Further Information
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After you have:
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Contacted the CDDO,
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Completed the SMRH Service Request Form, and
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Submitted the SMRH Service Request Form to the Parsons State Hospital & Training
Center or to your CDDO.
You will also need to fill out these forms for Outreach OR Inpatient Services. You will need the free
Adobe
Acrobat Reader to view/print the files listed below.
Consent for Videotape
General Release of
Information
Consent for Evaluation and
Treatment
Checklist
NOTE: Please, be sure to have all documentation signed and
witnessed by staff
prior to sending it to our intake coordinator, Karen Van Leeuwen at (800)362-0390,
extension 1788. Outreach Services cannot be rendered without a signed “Consent
for Evaluation and Treatment.”
If you need help completing these forms, contact Karen Van Leeuwen at
(800)362-0390, extension 1788.
Send the completed forms to Karen Van Leeuwen in any of the following ways:
U.S. Mail:
Parsons State Hospital & Training Center
Attn. Karen Van Leeuwen
P.O. Box 738
Parsons, KS 67357
FAX:
(620) 423-0419
eMail:
Karen.VanLeeuwen@pshtc.ks.gov
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