Eagle County Collaborative Management Program(CMP) ISST Referral Form
Thank you for your commitment to youth and families. An ISST (Individualized Service and Support Team) meeting is voluntary, family-focused and family-driven. The purpose is to bring providers and families together to develop an integrated service plan that will help ensure better outcomes for the youth involved in multiple systems.

TO QUALIFY FOR AN ISST MEETING WITH EAGLE COUNTY CMP, A YOUTH MUST:
1) Reside in Eagle County,
2) Be between 0 - 18 years old,
3) Be involved in at least two systems (see Question 3 below for list of systems).

IF THE YOUTH IS AN EAGLE COUNTY SCHOOLS STUDENT AND ATTENDS THE FOLLOWING SCHOOLS, PLEASE EMAIL THE SCHOOL PREVENTION SPECIALIST LISTED BELOW TO REQUEST AN ISST (DO NOT COMPLETE THIS FORM).

For Eagle Valley High School, Eagle Valley Middle School and Gypsum Creek Middle School, please email Candace Eves at Candace.Eves@eagleschools.net to schedule an ISST.

For Battle Mountain High School, Berry Creek Middle School and Homestake Peak (6-8th grade only), please contact Hannah Ross at Hannah.Ross@eagleschools.net to schedule an ISST.

TO MAKE A REFERRAL, IF THE YOUTH IS NOT ATTENDING ONE OF THE SCHOOLS MENTIONED ABOVE, PLEASE READ THE FOLLOWING:

1) Only CMP Interagency Oversight Group partner agencies can make referrals. See Question 2 on the form for partner list.

2) You or someone at your partner agency needs to serve as the main contact person that works with the family and the other providers to monitor the progress of the service plan that will be developed at this meeting.

3) Obtain the parent or guardian's signature on the CMP Informed Consent. Copy this link to your browser to download the informed consent: https://drive.google.com/file/d/1_RZ2Wbm5q9Dgyda8Eegv8DTldlvKlx1Y/view?usp=sharing

4) The youth must be involved in multiple systems AT THE TIME OF THE REFERRAL (see Question 5 for list of systems).

5) Every effort will be made to schedule an ISST meeting no later than 2 weeks from the date you submit this form.

6) The CMP Coordinator will review this form upon submission, contact you with questions and work together with you on inviting other providers to the ISST meeting.

7) Referrals will be accepted beginning in mid-August through May 1. If an ISST is needed during the summer, please contact the CMP Coordinator prior to completing this referral form. Her contact information is listed below.

FOR QUESTIONS, PLEASE CONTACT:
CMP Coordinator Gloria Cueva, gcueva@eagleyouth.org, (w)970.949.9250 (c)512.569.9100.

NOTE: The CMP Coordinator serves as a neutral facilitator of the ISST meeting, not the case worker. CMP has funds that can utilized for services for the youth and family involved in the ISST, with the prerequisite that CMP be the payee of last resort. Other avenues of funding such as scholarships or financial assistance programs will be explored first.

Email address *
1. What is today's date? *
MM
/
DD
/
YYYY
2. Your Agency's Name (must be CMP IOG partner) *
3. Your Name (or that of the person who will work with the family) and Phone Number *
4. Name of Youth Being Referred and Youth's Age *
5. What systems is the youth involved in? *
Check all that apply. You must check at least two systems.
Required
6. You must be able to check all three boxes below in order for the youth to qualify for a referral and for you to continue this referral. *
Required
7. If in school, what school does youth attend?
8. Youth's Date of Birth (dd/mm/yyyy) *
9. Gender of Youth *
10. Youth's Race *
11. Is the youth of Hispanic or Latino origin? *
12. Youth's Strengths and Interests *
Include strengths of the youth and family, if you know some of their strengths. List any interests the youth has and/or activities that the youth participates in.
13. Concerns and Needs for this Youth *
What are the issues facing this youth and his family, if you know any of the challenges facing the family, too?
14. Suggested Participants
These can include school representatives, providers of services, staff at systems the youth are involved with and anyone else that the family might want to include such as extended family, pastor, or friends. Include contact information, if you have it on hand. If you are unsure, you can wait to answer this when you speak with the CMP Coordinator.
15. Preferred Days of Week for ISST Meeting *
Check all that apply. (Tuesdays and Fridays not available.)
Required
16. Preferred Hours for ISST Meeting *
Check all that apply.
Required
17. Is an interpreter needed for the meeting
18. Names and Ages of Siblings Living at Home
19. Legal Guardian(s) *
Enter name, phone number and relationship to the youth. You may enter more than one legal guardian's name.
20. Name of Legal Guardian the Youth Lives with *
21. Mailing Address of Legal Guardian
22. City where Youth and Legal Guardian Reside *
Upload the CMP Informed Consent Form *
Required
Submit
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