Contact:
Date: SELECT
Agency:
Phone:
Fax:
Email: *
Date of Birth:
Sex: Male Female
Race:
SSN#:
Medicaid #:
Biological Parent(s):
Relative
Foster Family
Other Specify:
Legal Guardian: DSS - Specify Biological Parent(s) Other - Specify
Specify:
Current Treatment: Outpatient Services Psychiatric Other (Please specifv)
Please Check all that apply.
History/Current: Sexual Offending Behavior Physical Aggression Toward Other Physical Aggression Toward Property Verbal Aggression Stealing Fire Setting Runaway within past two months Non-compliance with rules Multiple School Suspension Current Drug Use Gang Involvement Hx of Sexual Abuse {victim) Hx ofPhysical Abuse (victim) Other
Other:
Behavioral/Crisis Plan or does child require restrictive interventions?
Medications:
Services Required: Individual Family Collateral Group Psychiatric Other
(Past 6 Months)This includes any hospitalizations, detention, or other out of home placement
Willi racial/cultural preference affect placement?
Willi religious preference affect placement?
Willi location affect placement?
Is there a history of drug or alcohol abuse?
Current drug treatment?
Educational History? Long-Term Suspensions/expulsion BED Special Education Current IEP Current Alt School Placement Regular Classes
Level of family involvement?
Current Medical Problems:
Date of Last Physical:
Is there a history of violence or criminal activity? Felonies Probation
If yes, please provide explanation.
Comments (Include Placement Deadline)
Funding Source if known (check all that apply): Area Program/Medicaid DSS Private Insurance Other CTSP/Target Population
Effective Date: SELECT
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Password
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