Forms and Information

Here you can find all of the CYC-I forms for download. Click the form name on the left to begin the download. If you have questions, please contact us online.

Consent to Obtain and Consent to Release Information forms signed by the legal guardian are required when Care Coordination services are delivered. The Consent to Obtain and Consent to Release Forms can be faxed to the CYC-I coordinator at 641-782-9519.

Intake Information

CYC-I project requires the following information regarding the patient in order for the CYC-I Child Psychiatrist to consult with a PCP. Individually identifiable patient information should not be discussed/provided unless the appropriate Consent to Obtain information form has been signed by the patient’s legal guardian. The information can be called to the CYC-I intake line or completed in the CYC-I Consult Request form and faxed to the CYC-I Coordinator. See Appendix C for the CYC-I Consult Request Form.
  1. Name and address of requesting provider
  2. Call back phone number and best time to reach the requesting provider
  3. Patient’s age
  4. Patient’s gender
  5. Reason for requesting the consult
  6. Current Mental Health and Medical diagnosis’s
  7. General Question for Child Psychiatrist
  8. Rating of complexity of child’s care
  9. Insurance type

If the appropriate Consent to Obtain information form has been signed by the patient’s legal guardian, then CYC-I will request additional information to deliver Care Coordination services.

After Consult Summary

The CYC-I Child Psychiatrist will send a summary of the consult to the PCP.

Satisfaction Survey

A brief survey will be completed by the PCP after each consult. This information is vital in our efforts to ensure we meet the Primary Care Provider’s needs. We will also use this information as we approach stakeholders for support to sustain and expand the CYC-I project.
Child Health Specialty Clinics
100 Hawkins Drive    Iowa City, IA 52242
Phone (855) 275-4444    Fax (641) 782-9519
© 2017 Child and Youth Psychiatric Consult Project of Iowa (CYC-I). All Rights Reserved.
Primary Care Providers call the CYC-I Intake line at 855-275-4444
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