Prepare a referral the receiving team can follow

Organize the work before collecting files

A referral packet brings together records held by several people: a clinician may hold the assessment, a guardian may have identity documents, and a school or social worker may hold education and custody records. Start with a working list that identifies each requested document, who can supply it and whether it is current. That is more useful than a folder full of files whose status nobody can explain.

Use Keystone's admission portal checklist as the source for the order of submission. Its three stages separate initial clinical review, mandatory admission documents and additional WS/FCS forms for children in DSS custody. Do not treat a shorter personal checklist as a replacement for the full list. A document that is conditional should retain its condition, rather than being silently omitted or requested from every family.

Send the initial clinical records first

Step 1 asks for the most recent records in this order: Comprehensive Clinical Assessment (CCA), CCA Addendum if available, Person-Centered Plan (PCP), and Psychological Evaluation if available. This first group lets the team begin reviewing eligibility. The portal accepts multiple uploads, so a referrer does not have to hold those records until every other item is collected.

The initial addendum's optional status does not make it optional for authorization. Placement cannot occur without an MCO authorization, which requires a CCA addendum dated within 30 days recommending Level III and a PCP update recommending Level III with a signed Service Order in section 3. The Service Order must be signed by a licensed physician, physician assistant or nurse practitioner; without it, authorization and admission cannot proceed.

Give the mandatory set its own review

Step 2 begins with the Completed Resident Admission Application and Signed Consent Forms. It then requests a Complete CCA within one year, an Updated CCA within 30 days of admission recommending Level III, a CALOCUS Assessment indicating a Level III recommendation, an Updated PCP Document in Word format, and Service Order with Signatures within 30 days of the admission date. Check both dates and completeness; a recently uploaded file is not necessarily a recently completed document.

The remaining mandatory list includes IEP/504 Documentation if applicable, Current School Records, Health Records and Immunization Details, Custody Order Documentation, Court Orders if applicable, Medicaid Card, Birth Certificate, Social Security Card, Guardian Identification and a 30-Day Prescription Record. Preserve the portal's full labels and order when working through the list. If a requested custody record does not match the child's circumstances, ask admissions how to document the legal authority rather than assuming DSS custody is required for all placements.

The final Step 2 item is prescriptions sent to the program's pharmacy: Lewisville Drug Company, 6715 Shallowford Road, Lewisville, NC 27023, (336) 946-0220. Coordinate that task with the responsible prescriber and care team. A prescription record in an uploaded packet and prescriptions sent to the pharmacy are separate requirements; completing one should not be mistaken for completing both.

Handle school forms and file quality deliberately

For a child in DSS custody enrolling in Winston-Salem/Forsyth County Schools, Step 3 requests WS/FCS New Student Enrollment, Verification of Custody letter (DSS 5760), Notification of Placement Change (DSS 5133), and Immediate Enrollment Form (DSS 5135), in that order. Obtain the DSS forms through DSS. Do not create a substitute document or assume those additional forms replace the school records requested in Step 2.

Before uploading any group, open the files and check that every page is readable and belongs to the intended child. Use clear document names that help distinguish updates, while avoiding unnecessary sensitive information in file names. Keep track of what was actually submitted, not just what someone promised to send.

• Check for missing pages, incomplete fields and required signatures.
• Separate current documents from older versions so the team can identify the update.
• Record outstanding items with the responsible contact and the next action.
• Flag conflicting information for the appropriate professional rather than altering the record.

Make each submission easy to identify

The upload form collects the child's name and date of birth, the documents included, attachments, and the referring agent's name, email and phone. Submissions are private and used solely to evaluate the prospective resident's admission. Use the admission portal for the records and contact the admissions team when you need clarification about a missing or updated item.

A complete referral supports review; it does not guarantee acceptance, authorization or a particular move-in date. Initial review is typically completed within 2–4 weeks of receiving a complete referral. To clarify readiness or a document question, call (855) 551-5397 or email admin@keystonecn.org.