ADMISSION CHECKLIST - Alexander Youth Network



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Referral Form

(Not required when Cardinal MCO application received)

Name of person completing form:     

Agency:     

Contact information: Phone:       E-mail:     

Date:     

Service(s) Requested, select from drop-down menus below:

1. 2. 3.

Date of most recent assessment (CCA), if applicable:      

If additional space is needed for any question, add a note at the end of this form. Be sure to give the question number for reference.

I. Family Information

Child:

1. Child’s Name:                  2. Nickname:      

Last First Middle

3. Date of Birth:                   4. Verified? Yes 5. Gender: Female: Month Day Year No Male:

6. Race:      7. Social Security No:      -     -     

8. Place of Birth:                  

City State Country

9. Currently Living With: Biological Parents: Relative: Foster Family: Other:      

(Specify)

Parents:

Mother

10. Name:                   11. DOB:      /     /     

Last, First Middle Month Date Year

12. Address:                  ,            

Number, Street, Unit City, State Zip Code

13. Phone Number: (     )      -      14. Race:      

15. Religion:       16. Marital Status: single married separated divorced

Father

17. Name:      ,             18. DOB:      /     /     

Last, First Middle Month Date Year

19. Address:                  ,            

Number, Street, Unit City, State Zip Code

20. Phone Number: (     )      -      21. Race:      

22. Religion:       23. Marital Status: single married separated divorced

24. Have proceedings been initiated to terminate parental rights for this Child’s: Mother Father:

If yes, give the date of the final order terminating parental rights of the Mother:       Father      

25. Has Child been adopted: Yes No . If yes, give dates of the final adoption order(s):      

II. Custody

Legal Custodian: Same as above Parent Information:

26. Name:                   27. Phone Number: (     )      -     

Last, First Middle

28. Address:                              

Number Street , Unit City State Zip Code

Month Date Year

III. Presenting Problem

Please tell what is going on in the family at this time. Describe the significant events which affect this family and child:

     

If additional space is needed for any question, add a note below and be sure to give question number for reference.

     

IV. FAMILY RELATIONSHIPS

CHILD’S SIBLINGS (Include child’s biological, half, step, and adoptive siblings):

1. Name:       Telephone:       Relationship:      

Address:      

Number Street Name Unit City State Zip

2. Name:       Telephone:       Relationship:      

Address:      

Number Street Name Unit City State Zip

3. Name:       Telephone:       Relationship:      

Address:      

Number Street Name Unit City State Zip

4. Name:       Telephone:       Relationship:      

Address:      

Number Street Name Unit City State Zip

If child’s current family has DSS involvement, please indicate reason for involvement and/or removal:

     

PREVIOUS PLACEMENTS: (If applicable: Include relative, foster, residential placements):

1. Name:       Telephone:       Type of placement:      

Address:      

Number Street Name Unit City State Zip

2. Name:       Telephone:       Type of placement:      

Address:      

Number Street Name Unit City State Zip

3. Name:       Telephone:       Type of placement:      

Address:      

Number Street Name Unit City State Zip

4. Name:       Telephone:       Type of placement:      

Address:      

Number Street Name Unit City State Zip

V. EDUCATION

1. Current/Last School:       1b. Location:      

2. Current/Last Grade:      

3. Has child been classified as special needs? Yes No If Yes, specify category:      

4. Psychological Evaluation Date:       Results:     

5. Check applicable school issues:

Inconsistent school attendance Poor Academic Progress

Expulsion/Suspension Truancy

Behavior Problems Other, Specify:      

VI. MEDICAL

1. Current Medical Issues:       2. Allergies:      

3. Date of Last Physical:       3b. Physician Name:      

MM/DD /YYYY

4. Date of Last Dental Exam:       4b. Dentist Name:      

5. Name current medications:      

MM/DD /YYYY

VII. Other

Goal for Foster Care:

Other:      

Guardian Signature: Date:

Treatment Foster Care Matching Criteria

Please check each box that accurately describes the client being referred (and describe in detail below):

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|Placement Criteria |This is absolutely |I prefer it, but have some |

| |required |flexibility |

|Preferred number / gender of Treatment | | | |

|Parents in the home: | | | |

|Preferred number, age, gender of other | | | |

|kids in the home? | | | |

|Is there a concern about pets being in the| | | |

|home? | | | |

|Does the child require a private room, or | | | |

|is he or she able to share a room with | | | |

|another child? | | | |

|Is the custodian requesting to meet the | | | |

|identified family in advance? | | | |

|Is the location of the home a factor? | | | |

|Please note preferred counties or regions.| | | |

|School preference (public school in the | | | |

|area of identified foster home, or day | | | |

|treatment): | | | |

|Long-term plan for child: | |

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|Other pertinent info: (please include a description of client’s current behaviors and triggers) |

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The following pages are to be completed for foster care referrals ONLY.

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