Today’s Date: - North Homes Children and Family Services



-1223010-635Today’s Date: FORMTEXT ?????Date Placement Needed By: FORMTEXT ?????Referral All information contained in this placement referral is strictly confidential. Please fax to ensure continued confidentiality.Youth Name (First, Middle, Last) FORMCHECKBOX M FORMCHECKBOX FDOB: FORMTEXT ????? Age: FORMTEXT ?????Type of Referral: FORMCHECKBOX 35 Day Evaluation FORMCHECKBOX Stabilization/90 Day Intensive Treatment FORMCHECKBOX Secure Detention FORMCHECKBOX Professional Foster Care FORMCHECKBOX Residential Treatment Cottage or Girls residential treatment FORMCHECKBOX Boys Program FORMCHECKBOX Boys Teens In Transition FORMCHECKBOX SEY program Youth S.S. Number: FORMTEXT ????? Race: FORMTEXT ????? If applicable, Tribe: FORMTEXT ?????Youth’s Current Residence: FORMTEXT ?????InformationReferral Source Name: FORMTEXT ?????Title: FORMCHECKBOX SW FORMTEXT ????? County FORMCHECKBOX CMH FORMTEXT ????? County FORMCHECKBOX PO FORMTEXT ????? County FORMCHECKBOX Parent FORMTEXT ????? Custody Type FORMCHECKBOX TW FORMTEXT ????? Tribe FORMCHECKBOX Other: FORMTEXT ?????Referral Contact InformationDirect Line: FORMTEXT ????? Mailing Address: FORMTEXT ?????Cell: FORMTEXT ????? Email Address: FORMTEXT ?????Fax: FORMTEXT ?????Type of Placement: FORMCHECKBOX Court Order FORMCHECKBOX Social Service FORMCHECKBOX Voluntary FORMCHECKBOX Other: FORMTEXT ?????A copy of the hold/placement agreement will be required upon placement. This includes ICPC paperwork.FAMILY INFO:Adoptive/ Bio/StepMailing AddressDate of BirthFather FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Has Custody FORMCHECKBOX Full Name: FORMTEXT ????? Home Phone: FORMTEXT ????? Cell Phone: FORMTEXT ????? TPR: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX In ProcessMother FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Has Custody FORMCHECKBOX Full Name: FORMTEXT ????? Home Phone: FORMTEXT ????? Cell Phone: FORMTEXT ????? TPR: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX In ProcessSiblings FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????? FORMTEXT ?????Limits to contact FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????? FORMTEXT ?????Limits to contact FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????? FORMTEXT ?????Limits to contact FORMTEXT ????? FORMCHECKBOX M FORMCHECKBOX F FORMTEXT ????? FORMTEXT ?????Limits to contact FORMTEXT ?????Are there any restrictions on either parent’s involvement? If so, please indicate here: FORMTEXT ?????Referral Source Narrative: FORMTEXT ?????Youth’s Previous PlacementsYearReasonAgency / Location FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Has youth received previous services from NHCFS in either Bemidji or Duluth locations? If yes, indicate below. FORMCHECKBOX Yes FORMCHECKBOX No FORMTEXT ????? FORMTEXT ?????Youth’s Previous OffensesYearOffense (also explain the original charges if you are on probation)Outcome FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalersName of Current Pharmacy: FORMTEXT ?????Pharmacy Phone Number: FORMTEXT ?????Name of Drug Strength / MgFrequency TakenName of Prescriber & Clinic Associated With FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Allergies ToReaction Had FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????HistoryAll questions contained in this questionnaire will be kept strictly confidential.Abuse History FORMCHECKBOX Neglect Perpetrator(s): FORMTEXT ????? FORMCHECKBOX Physical Perpetrator(s): FORMTEXT ????? FORMCHECKBOX Emotional/Psychological Perpetrator(s): FORMTEXT ????? FORMCHECKBOX Sexual Perpetrator(s): FORMTEXT ?????Risk of Harm to SelfIs there a history of cutting or self injurious behavior (SIB)? FORMCHECKBOX Yes FORMCHECKBOX NoIs there a history of suicidal ideation? FORMCHECKBOX Yes FORMCHECKBOX No# of suicide attempts? FORMTEXT ?????Current risk of suicide FORMCHECKBOX Hi FORMCHECKBOX Med FORMCHECKBOX LowFASD FORMCHECKBOX None FORMCHECKBOX Suspected FORMCHECKBOX Requesting Diagnosis FORMCHECKBOX Has DiagnosisIf diagnosed, name of Diagnostic Clinic/Professional? FORMTEXT ?????Risk of Harm to OthersHistory of Sexual Behaviors or Talk? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, please describe? FORMTEXT ?????Has the youth successfully completed treatment to address the behaviors/talk? FORMTEXT ?????History of cruelty to animals? FORMCHECKBOX Yes FORMCHECKBOX NoVerbally abusive to others? FORMCHECKBOX Yes FORMCHECKBOX NoPhysically abusive to others? FORMCHECKBOX Yes FORMCHECKBOX NoGang involvement? FORMCHECKBOX Yes FORMCHECKBOX NoDifficulties with peer relationships? FORMCHECKBOX Yes FORMCHECKBOX NoRun RiskHistory of running away? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Recent – time gone: FORMTEXT ????? FORMCHECKBOX months ago: FORMTEXT ????? FORMCHECKBOX years ago: FORMTEXT ????? FORMCHECKBOX N/A: FORMTEXT ?????# of runs: FORMTEXT ?????Places youth goes: FORMTEXT ?????HomelessnessDoes the youth have a history of being homeless? FORMCHECKBOX Yes FORMCHECKBOX NoDrugs / AlcoholDoes youth currently use recreational or street drugs? FORMCHECKBOX Yes FORMCHECKBOX NoDoes youth currently use alcohol? FORMCHECKBOX Yes FORMCHECKBOX NoMental HealthDoes the youth have an eating disorder or suspected eating disorder? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the youth have grief or loss suffering? FORMCHECKBOX Yes FORMCHECKBOX NoIf so, describe loss and month/season it occurred: FORMTEXT ?????Does the youth have difficulty with parental relationships? FORMCHECKBOX Yes FORMCHECKBOX NoAdditional QuestionsLying or Cheating concerns? FORMCHECKBOX Yes FORMCHECKBOX NoEnuresis or Encopresis history/current concern? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the youth have vision or hearing loss? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the youth have history of gang involvement? FORMCHECKBOX Yes FORMCHECKBOX NoIs there a history or concern of truancy or lack of academic motivation? FORMCHECKBOX Yes FORMCHECKBOX NoDoes the youth have identity issues? FORMCHECKBOX Yes FORMCHECKBOX NoIs there a current diagnostic/functional assessment? FORMCHECKBOX Yes FORMCHECKBOX No Date: FORMTEXT ????? Clinic/Doctor: FORMTEXT ?????Specific goals for the youth to accomplish: FORMTEXT ????? Is youth on an IEP? FORMCHECKBOX Yes FORMCHECKBOX No Last School Attended: FORMTEXT ????? Grade: FORMTEXT ?????Strengths of youth/family: FORMTEXT ?????Physical restrictions for the youth: FORMTEXT ????? The developmental, educational, cultural, and mental health needs can be met by the program: FORMCHECKBOX Yes FORMCHECKBOX NoPrimary Physician and Dentist – Please provide Name of Clinic, Physician, Dentist and Phone#: FORMTEXT ?????INSURANCE INFORMATION - A Copy of Insurance card is requiredName of Primary Insurance: FORMTEXT ????? Is this a PMAP? FORMCHECKBOX Yes FORMCHECKBOX NoHas the placement been approved by the PMAP? FORMCHECKBOX Yes FORMCHECKBOX NoHave you requested a faxed confirmation? FORMCHECKBOX Yes FORMCHECKBOX NoAddress of Insurance: FORMTEXT ????? Telephone number: FORMTEXT ?????Name of Insured: FORMTEXT ????? Relationship to Youth: FORMTEXT ????? Insured DOB: FORMTEXT ?????Insured ID Number: FORMTEXT ????? Group Number: FORMTEXT ????? Name of Insured Employer: FORMTEXT ?????Is there a Secondary Insurance? FORMCHECKBOX Yes FORMCHECKBOX NoName of Secondary Insurance: FORMTEXT ?????Address of Insurance: FORMTEXT ????? Telephone number: FORMTEXT ?????Name of Insured: FORMTEXT ????? Relationship to Youth: FORMTEXT ????? Insured DOB: FORMTEXT ?????Insured ID Number: FORMTEXT ????? Group Number: FORMTEXT ????? Name of Insured Employer: FORMTEXT ?????Requested additional serviceAdditional services requested. Specific information can be added in the space provided. FORMCHECKBOX Psychological Diagnostic: FORMTEXT ????? FORMCHECKBOX Family Assessment: FORMTEXT ????? FORMCHECKBOX Medication Management: FORMTEXT ????? FORMCHECKBOX Psychiatric Diagnostic: FORMTEXT ????? FORMCHECKBOX Individual Therapy: FORMTEXT ????? FORMCHECKBOX Specific Medical/Dental Care: FORMTEXT ????? FORMCHECKBOX Rule 25 and/or CD Care: FORMTEXT ????? FORMCHECKBOX Family Therapy: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX CTSS/MHBA: FORMTEXT ????? FORMCHECKBOX Adoption Services: FORMTEXT ????? FORMCHECKBOX Religious / Cultural Needs: FORMTEXT ????? FORMCHECKBOX Free at Last / Evergreen: FORMTEXT ????? FORMCHECKBOX Community Service Hours: FORMTEXT ????? FORMCHECKBOX Driver’s Training: FORMTEXT ????? ................
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