Referrals

WHAT WE DO

The advocates at the Cherish Center are able to connect you with an array of services. This may include trauma therapy, medical services, Youth Assistance Program, as well as many other resources. We have several partner providers that can help meet your needs. If you’re interested in a referral, reach out to one of our advocates and they’d be happy to assist!

Advocacy

We work with several trauma therapists located at both Cherish and in the community. You may qualify for financial assistance for trauma therapy, if needed. If so, refer to the application below.

Therapy Services

Financial Assistance Application

Client Name(s)

Parent/Guardian Name

First Name

Last Name

Today's Date

MM

DD

YYYY

Email

Name of Child

First Name

Last Name

Legal Guardian

First Name

Last Name

Additional Legal Guardian

First Name

Last Name

Relation to Child

Phone Number

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

May we leave a voice message if no answer

Is Financial Assistance needed in order to obtain services

Explanation of need for financial assistance:

You may be asked to show proof of need for financial assistance.

Do you fall at or below the 138% poverty guideline?

If not, you must provide proof of need (proof of income and expenses.) Persons in Household (Col. 1) - FPL100% (Col. 2) -FPL138% (Col. 3) 1 $12,060 -$16,642 2 $16,240 - $22,411 3 $20,420 - $28,179 4 $24,600 - $33,948 5 $28,780 - $39,716 6 $32,960 - $45,484 7 $37,140 - $51,253 8 $41,320 - $57,021 Add $4,160 for each additional person if household has more than 8 people

Is there a Divorce Decree or other Court Order in place affecting the child?

With whom does the child live? List all household members.

Date seen at Cherish

MM

DD

YYYY

Type of Abuse or Trauma

Alleged Perpetrator's Relationship to Child

DCS Contact

First Name

Last Name

Law Enforcement Contact

First Name

Last Name

Other than the child listed above, who is being referred for trauma therapy as it pertains to your Cherish visit?

Name of Individual Completing Form

First Name

Last Name

Date Completed

MM

DD

YYYY

I understand:

- Cherish has an obligation to keep my personal information, identifying information, and my records confidential. I also understand my information will be shared among the Cherish Multidisciplinary Team in order to provide effective case management and I can choose to allow Cherish to release some of my personal information to certain individuals or agencies. - I do not have to complete a release form. I do not have to allow Cherish to share my information. Completing a release form is completely voluntary. - Releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from Cherish. - The risks and benefits of releasing the confidential information to the above organization or person. - A limited release of information can potentially open up access by others to my confidential information held by Cherish. - The specific information I want to be released and how it will be shared. I understand email is not confidential. - Cherish and I may not be able to control what happens to my information once it has been released and that the agency or person getting my information may be required by law or practice to share with others. - This release is valid when I check this box and complete this form and I may withdraw my consent to this release at any time either verbally or in writing. By checking this box and submitting this form, I acknowledge I have read these policies and I consent to services and/or referrals from Cherish. I authorize the release of the above stated information to Cherish. I further understand that this is not an acceptance of services and that Cherish has an ethical obligation to respect my right to privacy through the handling of information in a confidential manner. I hereby consent to authorize the release of information aforementioned.

I have read these policies and I consent to services and/or referrals from Cherish.

The purpose of a SANE is to assess the health and well-being of the child in a quiet, safe environment. A SANE will never be forced, and all control is left to the child. The exam can reassure that everything is okay with the child’s body, treat medical conditions that may or may not be related to child abuse, while providing emotional support and age-appropriate communication. The nurse will recommend any follow up, provide resources, and meet individually with caregivers to discuss any concerns and exam findings.

Sexual Assault Nurse Examination (SANE)

The Center for Hope Clinic at Peyton Manning Children’s Hospital: Visit the ER or call 317-338-3153

Community Hospital- Anderson: Visit the ER or call 765-298-5598 -assesses sexual assault only

Community Hospital Anderson

Ascension St. Vincent

Hamilton County Youth Assistance serves as an early intervention advocate for youth ages 3-17 who are facing challenging life circumstances. They take a holistic approach to coordinate our community’s vast array of talents, services and resources to help youth and empower parents and caregivers. For more information, follow the link below. Reach out to one of our advocates if you’d like Cherish to make a referral on your behalf.

Youth Assistance (YAP)

Hamilton County Youth Assistance