ATTACHMENT 4.pdf

Attachment 4

Form 405B 03-2022

MULTI-AGENCY CHILDREN’S SERVICES REFERRAL APPLICATION

Date of Referral: ________________ Date Placement is Needed: _________________________

Type of Referral:

Intensive Group Care (GCIS) Independent Living Group Care Residential Treatment Facility (PRTF) Temporary De-escalation Care/ Short term Alternative Placement (STAP)

Qualified Residential Treatment (QRTP)

Intermediate Group Care (GCMS) Emergency Shelter Therapeutic Foster Homes (TFC) Qualified Residential Treatment (QRTP) Other: __________________________________________

Referring Agency: � COC � DDSN � DJJ � DMH � Other: ______________________________________

Case Manager’s Name: __________________________________________________

Phone Number: __________________ Email: ____________________

Address: _____________________________________________

CLIENT INFORMATION

Client’s Name: __________________________________________________________________

Alias/Nickname: _________________________________________________________________

Date of Birth (MM/YYYY): ___________________________

Age: _______ Gender: ______ Race: ____________ Height: ____ Weight: _____

Religious Affiliation: � Protestant � Catholic � Muslim � Jewish � None � Other: _________________________________

Place of Birth: _______________ County of Legal Custody: ____ Legal Custodian: ________________ Relationship to Client:

Address: ________ Telephone Number: ____

Hobbies: _____________________________________________________________________________

Strengths:

(Check all that apply)

� Strong Family Base � Appropriate Reading Level � Average/Above IQ

� On Grade-Level � Good Verbal Skills � Good Personal Hygiene

� Good Socialization Skills � Appropriate Coping Skills

Other: ________________________________________________________________

Reason for Referral: _____________________________________________________________________

Client’s Current Placement: _________________________________________________________

� Intermediate Group Care � Residential Treatment Facility

Independent Living Group Care Therapeutic Foster Home

� Other ______________________________________

Type of Facility:

Intensive Group Care Temporary De-escalation Care/

Short Term Alternative Placement

Number of Previous Placements:

� 0-3 � 4-6 � 7-10 � More than 10

Page 2 of 7 Form 405B 03-2022

Attachment 4 Placement History (Please list all placements including psychiatric hospitalizations. Attach additional page(s) if necessary.)

Use format of Dates of placement (From/To), Name of Placement, Reason for Discharge.

Current Behavioral Problems/Weaknesses (Check all that apply):

� Abandonment Issues � Aggressive (Physical) � Aggressive (Sexual) � Aggressive (Verbally) � Alcohol/Drug Abuse � Antisocial Behavior � Anxiety � Arson � Bedwetting � Below Grade Level � Cruelty to Animals � Delusional � Depression � Destroys Property � Difficulty with Authority � Developmentally Delayed � Fire Setting � Functionally Illiterate � Eating Disorder � Hyperactive � Impulsive � Homeless � Loss/Grief Difficulties � Low IQ/Mental Retardation � Low Self-Esteem � Oppositional/Defiant � Parental Neglect Issues � Phobic Reactions/Behavior � Physical Disability: ___________ � Poor Coping Skills � Poor Personal Hygiene _____________________________ � Poor Reality Orientation � Poor Social Skills � Problems at School � Running Away � Self-Destructive Behavior � Sexually Acts Out � Sexually Provocative � Sibling Related Difficulty � Suicidal Gestures � Suicidal Ideation � Steals � Truancy � Unruly/Ungovernable � Other: _____________________ � Other: _____________________ � Other: _____________________

Client has been a victim of (check all that apply):

� Allegation � Allegation � Allegation

Neglect Physical Abuse Sexual Abuse Emotional Abuse Human Trafficking

Allegation Allegation

Substantiated-Perpetrator: _______________________ Substantiated-Perpetrator:__________________________ Substantiated-Perpetrator: __________________________ Substantiated-Perpetrator: ___________________________ Substantiated-Perpetrator: ___________________________

Page 3 of 7 Form 405B 03-2022

MENTAL HEALTH AND HEALTH INFORMATION

DSM V Diagnosis Information (Please list: DSM V, Diagnosis, Date Diagnosed & Source)

Medication Information (list all current medications, dosages, and instructions):

Emotional/Behavioral Functioning (Findings from psychological assessments):

Medical Conditions (check all that apply): C= Current H= History of Anemia � C � H Anorexia � C � H Asthma � C � H Bulimia � C � H Burns � C � H Chicken

Pox � C � H Convulsions � C � H Eczema � C � H

Enuresis � C � H Encopresis � C � H Fainting � C � H Hay Fever � C � H Headaches � C � H HIV/AIDS � C � H Lice � C � H Measles � C � H Mumps � C � H Pink Eye � C � H Ringworm � C � H Seizures � C � H Sinusitis � C � H Sore

Throat � C � H STD(s) � C � H Tuberculosis � C � H

�C �H Other: _______________________________________________________ �C �H Other: _______________________________________________________ �C �H Other: _______________________________________________________

Date of Last Physical Exam: ______ Dental Exam: Eye Exam:

Dental Appliances: Yes No Contacts/Glasses: Yes No Allergies:

Special Dietary Needs: ______________________________________________________ Medicaid Number: __________________________________________________ Medical Insurance Policy Carrier, Number(s), Holder: ________________________

FAMILY INFORMATION

Legal Mother’s Name: ______________________________________________________________ Address: ________________________________________________________ Telephone #: ______ Race: ____ Educational Level (if known): _____ Criminal Record Yes No

Legal Father’s Name: _______________________________________________________________ Address: __________________________________________________________________________________

Page 4 of 7 Form 405B 03-2022

Telephone #: ______________ Race: ____ Educational Level (if known): _____ Criminal Record: � Yes � No Are the Legal Parents: � Married � Separated � Divorced � Mother Deceased � Father Deceased

� Other: __________________________________________________ Have Parental Rights Been Terminated? � No � Yes, date: ___________________________________ Name of Sibling(s) Current Placement

Family Contacts (Type of contact: T = telephone C = correspondence F = face-to-face O = other (specify))

Other Approved Contacts

Are there any special conditions/restrictions for home visits or furloughs? No Yes (explain):

There is a family history of (check all that apply for the biological/birth family):

� Child Abuse/Neglect � Criminal Activity � Treatment Disruption � Inappropriate Sexual Behavior � Psychiatric Illness � Other: ____________________________________

There is a family history of (check all that apply for the legal family):

� Child Abuse/Neglect � Criminal Activity � Treatment Disruption � Inappropriate Sexual Behavior � Psychiatric Illness � Other: ____________________________________

Provide a brief family history on education, behavior, development, adoption, psychosocial, legal (arson, stealing, sexual, burglary, and assault), parent’s psychiatric history, etc.:

Form 405B 03-2022

SCHOOL INFORMATION

District: Grade:

Learning Disabled Emotionally Disturbed Educable Mentally Disabled

Name of Last School Enrolled:

Special Education Classification:

Trainable Mentally Disabled Other Health Impairment Speech or Language Impairment Profoundly Mentally Disabled Hearing Impairment Visual Impairment Multiple Disabilities Deafness Deafness-Blindness Autism Traumatic Brain Injury Orthopedic Impairment None (Regular Education)

� Itinerant � Homebased (Special Education. Requires an IEP)

Delivery Model:

Resource Room Self-Contained Classroom Medical Homebound (Requires a physician’s order) Regular Education

Does the client have a current IEP? � Yes � No If yes, county and district that prepared it: ______

Does the client have a Section 504 plan? � Yes � No If yes, date: __________________________

Does the client have a history of truancy? � Yes � No

Has the client ever been suspended? Yes No If yes, when and why: _not abiding by school rules (cutting class, not following directions)_______________________

Has the client ever been expelled? Yes No If yes, when and why:________________________________

IQ/Achievement/Adaptive Testing Name of Test Date Administered Administered By Scores and Range (i.e., low average)

AGENCY/COURT INVOLVEMENT

Agencies Currently Involved with the Client:

Children’s Advocacy/Continuum of Care Department of Juvenile Justice Department of Vocational Rehabilitation Other: _____________________________________________

Department of Disabilities and Special Needs Department of Mental Health Department of Social Services

Page 6 of 7 Form 405B 03-2022

Attachment 4

Has the client ever been to court? Yes No If yes, indicate type of court and outcome:

Does the client have pending charges? Yes No If yes, list charges:

Is placement court ordered? Yes No If yes, attached a copy of the court order.

Is the client under intensive supervision? Yes No If yes, Officer:______________________________

Client’s Goals

Family’s Goals (if applicable)

Agency’s Goals

Educational Goals

TREATMENT GOALS

Page 7 of 7 Form 405B 03-2022

ADMISSION REQUIREMENTS CHECKLIST

(TO BE FORWARDED IF CLIENT IS ACCEPTED FOR PLACEMENT)

The referring agency will make every reasonable effort to supply the items listed in the Admission Requirements Checklist if the client is accepted for placement. If more information than is provided in the Children’s Services Referral Application is required to determine client eligibility for admission, the provider agency should request in writing the additional information from the referring agency.

ADMISSION REQUIREMENTS CHECKLIST

(IF ACCEPTED FOR PLACEMENT)

Medical Exam Most Recent Treatment Plan Current Medicaid /Insurance Card Most Recent Psychological/Psychiatric Evaluation(s) Previous Placement Discharge Summary(ies) Individual Education Plan (if applicable) Copy of Birth Certificate Immunization Records Completed Consent Forms (Program should forward to referring agency prior to admission) Copies of Court Orders Signed Homebound Form (if applicable) Pre-Admission Assessment (if applicable)

Name of Person Making Application: ______________________

Relationship to Client: ______ Telephone: ____________

Address: __________________________________

Signature:

Date: ______________________