ࡱ> vystue Mbjbj 9cbcbz8 8 8diY(%^v%v%v%&`(D)tXXXXXXX$[]Xi*&&**Xv%v%4#Y===*v%v%X=*X==UWv%)+VX9Y0iYVM_a,M_4WM_W)Z*@=R*4*w)))XX4)))iY****M_)))))))))8 B z: Department of Social Services Child Protection Services Department of Corrections Group/Residential Referral ApplicationLast Name: First Name: Middle Name:Date of Birth:Social Security Number: Male:  FORMCHECKBOX Female:  FORMCHECKBOX Race:Height: Weight: Medicaid Number:CID Number:Discharge Plan:Permanent Plan:Level of Service Please check the level of service that is being sought for the youth.Community Based ServicesNON-PRTF SERVICESPRTF SERVICES FORMCHECKBOX  Out of School Time FORMCHECKBOX  Short Term Assessment FORMCHECKBOX Residential Treatment FORMCHECKBOX  Independent Living FORMCHECKBOX  Professional Foster Care FORMCHECKBOX Intensive Residential Treatment FORMCHECKBOX  Crisis Stabilization FORMCHECKBOX  Therapeutic Emergency Foster Care FORMCHECKBOX  Respite Care FORMCHECKBOX  Group CareShort Term (30 120 days) FORMCHECKBOX  Community Reintegration FORMCHECKBOX  Group Care Long Term (6 to 12 months) Has the Child been reviewed by the State Review Team (SRT)?Yes  FORMCHECKBOX  No  FORMCHECKBOX  Date that placement is needed:      _________ Tribal InformationTribe:Enrollment Number: Family Services SpecialistName:Office:Email Address:Work Phone #:Fax Number: ______________ Cell Phone Number: _____________________ Supervisor:  Juvenile Corrections AgentName:Office:Email Address:Phone Number:Fax Number:Supervisor:  Emergency NumbersMother's Name:Father's Name:Telephone Number:Telephone Number:Person to Contact in case of Emergency:Phone NumberPerson or Relative child has been living with: SiblingsNameAgeAddress Materials to be Included FORMCHECKBOX Removal/Commitment Order giving Custody to the State FORMCHECKBOX Latest Report to the Court FORMCHECKBOX Initial Family Assessment or Juvenile Offender Intake Summary FORMCHECKBOX Copy of the Social Security Card FORMCHECKBOX Copy of Birth Certificate FORMCHECKBOX Copy of Most Recent Psychiatric Evaluation FORMCHECKBOX Copy of Most Recent Psychological Evaluation FORMCHECKBOX Copy of Discharge Summaries From Prior Placements School Record FORMCHECKBOX Current IEPCurrent Grade Level:IQ Score (if available): FORMCHECKBOX Report Cards FORMCHECKBOX Other Services Provided FORMCHECKBOX Speech FORMCHECKBOX Language FORMCHECKBOX Counseling by School FORMCHECKBOX Behavior Issues Medical Records FORMCHECKBOX EPSDT, Immunization Records, TB Test, Dental, Vision, HearingDates Of Last:TB Test:Dental Visit:Vision Test:Hearing Test:Physical Exam: FORMCHECKBOX List Allergies:  FORMCHECKBOX Current Medications:  FORMCHECKBOX Name & Phone Number of:Child's Doctor:Telephone: Child's Dentist:Telephone:  Placement History:Name of FacilityDates of ServiceCompleted Successfully FORMTEXT       FORMTEXT       To  FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       To  FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       To  FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       To  FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT       FORMTEXT       To  FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX   FORMCHECKBOX Abuse & Neglect History:   FORMCHECKBOX Drug / Alcohol History:  FORMCHECKBOX Child: FORMCHECKBOX Parents: FORMCHECKBOX Fetal Alcohol Spectrum Disorder Information: Who Can Child Have Contact With:Name Relation to StudentMonitoredYes  FORMCHECKBOX  No  FORMCHECKBOX Should the person above be invited to meetings related to the student?Yes  FORMCHECKBOX  No  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX Should the person above be invited to meetings related to the student?Yes  FORMCHECKBOX  No  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX Should the person above be invited to meetings related to the student?Yes  FORMCHECKBOX  No  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX Should the person above be invited to meetings related to the student?Yes  FORMCHECKBOX  No  FORMCHECKBOX Yes  FORMCHECKBOX  No  FORMCHECKBOX Should the person above be invited to meetings related to the student?Yes  FORMCHECKBOX  No  FORMCHECKBOX  FORMTEXT      Yes  FORMCHECKBOX  No  FORMCHECKBOX Should the person above be invited to meetings related to the student?Yes  FORMCHECKBOX  No  FORMCHECKBOX  No Contact ListName Relation to Student  FORMCHECKBOX Discipline used in last Placement:What worked?What did not work? FORMCHECKBOX Last Monthly Reporting Form:  FORMCHECKBOX BehaviorsAggression FORMCHECKBOX  Yes  FORMCHECKBOX  NoSexual Abuse FORMCHECKBOX  Yes  FORMCHECKBOX  NoSexual Behaviors FORMCHECKBOX  Yes  FORMCHECKBOX  NoFire Starter FORMCHECKBOX  Yes  FORMCHECKBOX  NoSuicidal Ideation FORMCHECKBOX  Yes  FORMCHECKBOX  NoSelf Harm FORMCHECKBOX  Yes  FORMCHECKBOX  NoRun Away FORMCHECKBOX  Yes  FORMCHECKBOX  NoHuffing FORMCHECKBOX  Yes  FORMCHECKBOX  NoDrug Use FORMCHECKBOX  Yes  FORMCHECKBOX  NoAlcohol Use FORMCHECKBOX  Yes  FORMCHECKBOX  NoCar Theft FORMCHECKBOX  Yes  FORMCHECKBOX  NoSexually Active FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf Sexual Behaviors category is marked yes: Was sexual offender treatment recommended, and if so has the child completed?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, where was sexual offender treatment completed at?  FORMCHECKBOX Please list any other behaviors that the child may need services for: FORMCHECKBOX Please describe or give examples of each item checked Yes or listed as other: Additional information that would be helpful to know to provide appropriate care for the child: Reasons For Placement / Desired Treatment Outcome: Discharge Plan. 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If No, please explain: In order to maintain safety and security within the facility it may be necessary to utilize seclusion and/or restraint at times.The guidelines for the use of seclusion/restraint are enforced through licensing regulations. Is the use of seclusion and restraint approved for this referral? 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