Administration for Childrens Services

ADMINISTRATION FOR CHILDREN’S SERVICES DIVISION OF YOUTH AND FAMILY JUSTICE

CASE MANAGEMENT YOUTH & FAMILY INTAKE Case Manager Name: Telephone Number: Facility: CRJC HJC NSD:

Case Manager Supervisor: Telephone Number: Initial Date of Date Intake Completed: Intake: YOUTH IDENTIFYING INFORMATION

1. Youth Name: (Last) (First) (MI) 2. DOB: 3. Age: 4. Primary Language: 5. Emergency Contact (Name/Telephone Number):

6. Preferred Name: 7. Alias/AKA: 8. Is the Preferred Name or Alias 9. Gang Affiliation: gang related? YES NO 10. What is the youth’s sex assigned at birth? Male Female Intersex *Note: An estimated one in 2000 babies is born with a reproductive or sexual anatomy and/or chromosome pattern that don’t seem to fit typical definitions of male or female. ‘Intersex’ is a general term used for a variety of conditions that cause these variations. 11. When a person’s sex and gender does not match, they might think of themselves as transgender. Sex is what a person is born. Gender is how a person feels. Which one response best describes the youth? I am not transgender I am transgender and identify as a boy or man I am transgender and identify as a girl or woman I am transgender and identify in some other way 12. A transgender youth has a right to use a preferred name and pronoun. Would the youth like us to use a preferred name and pronoun? YES NO If yes, what? 13. A youth’s appearance, style, dress, or the way they walk or talk may affect how people describe them. How does the youth think other people would describe them? Very feminine Mostly feminine Somewhat feminine Equally feminine and masculine Somewhat masculine Mostly masculine Very masculine 14. How does the youth describe their own experience, style, dress, or way they walk or talk? Very feminine Mostly feminine Somewhat feminine Equally feminine and masculine Somewhat masculine Mostly masculine Very masculine 15. Which of the following describes the youth’s sexual orientation? Heterosexual (straight) Lesbian Gay Bisexual Not sure/Questioning *Sexual orientation is who you are emotionally, romantically, and sexually attracted to.

1 ADMINISTRATION FOR CHILDREN’S SERVICES DIVISION OF YOUTH AND FAMILY JUSTICE

CASE MANAGEMENT YOUTH & FAMILY INTAKE 16. What is the youth’s race or ethnicity? Black/African-American Hispanic/Latino White (non-Hispanic) Asian or Pacific Islander Bi-racial – specify: Don’t know 17. Is the youth comfortable with their racial or ethnic identity? YES NO a. If no, specify: 18. Has the youth ever experienced racial prejudice or discrimination? YES NO a. If yes, specify: ADMISSION INFORMATION 19.Admit Date: 20. Admit Time: 21. Admit #: 22. Docket #: 23. Charges:

24. Remand Date: 25. Court: 26. High Profile/Media Case? YES NO a. If yes, list dates: LEGAL INFORMATION 27. Has the youth been previously detained? YES NO If no, skip to question 32. a. Where? 28. Did the youth encounter any problems while detained? YES NO a. a. If yes, with whom did the youth encounter problems? 29. Did the youth report these problems to a person of authority? YES NO a. If yes, to whom? 30. 30. Describe the nature of the problem: 31. 31. What concerns the youth most about being in detention? 32. 32. Does the youth understand what is happening with his/her 33. What does the youth think will happen with their case? YES NO case? 34. What is the youth’s attorney’s name 35. Does the youth have questions 36. Would the youth like to contact and telephone number? s/he needs to discuss with their their attorney? YES NO attorney? YES NO 37. Was the youth arrested with anyone a. If yes, with whom? b. What is this person’s relationship else? YES NO to youth? c. Is the youth intimidated by this person? YES NO d. Where is that person, currently? 38. Has the youth’s parents or legal guardian been to court for 39. Does the youth need another set of clothing for this case? YES NO court? YES NO 40. Does the youth think their parents/legal a. If no, would the youth like the case manager to call his/her guardian will come to court? YES NO parents/legal guardian and talk with them about this? YES NO FAMILY/PERSONAL INFORMATION 41. Mother/Mother (Parent 1): (Last) (First) (MI) 42. Father/Father (Parent 2): (Last) (First) (MI) 43. Legal Guardian: (Last) (First) (MI) a. Legal Guardian’s relationship to youth: 1. b. Is there documentation on legal guardianship? 2. YES NO 3. 44. Does the youth reside with someone other than their parent or legal guardian? YES NO a. a. If yes, person’s name/age/gender/relationship to youth/contact info: 1. 45. Is the youth in foster care a. Has this been verified by the ACS a. b. Specify Foster Care and/or NSP Provider or Non-Secure Placement? Confirm Unit? YES NO Name:

CASE MANAGEMENT YOUTH & FAMILY INTAKE YES NO

c. Foster care Case Worker or PPS Name/Tel. Number: d. Foster or PPS Supervisor Name/Tel. Number:

3. 46. Is the youth’s mother/father/legal guardian currently incarcerated? YES NO a. a. If yes, who/where (name of facility): 4. b. Has this been confirmed on the HHS Worker Portal? 5. c. Does the youth want to establish contact with them? YES NO YES NO 6. 47. Is the youth’s mother/father/legal guardian deceased? YES NO a. a. If yes, who/date of death: 48. Who is in the youth’s immediate Name/Relationship Name/Relationship Name/Relationship family? Name/Relationship Name/Relationship Name/Relationship

Name/Relationship Name/Relationship Name/Relationship 7. 49. Does the youth have any worries about his/her family or home life? YES NO a. a. If yes, specify: 8. 50. Does the youth have siblings or relatives currently in detention? YES NO a. a. If yes, who/relationship to youth/name of facility: 51. Does the youth have any a. If yes, how many? b. Name(s)/Age(s): children? YES NO c. Whom do/does the child/children reside with (name and d. Does that person have legal custody/temporary contact information)? guardianship of the child/children? YES NO 52. When is the last time the youth saw 53. Is there a legal stipulation that prevents the youth from having any the child/children? contact with the child/children? YES NO a. If yes, specify: HOUSING 1. 54. Is the youth currently experiencing housing problems? YES NO a. a. If yes, specify the nature of the problem: 2. 55. Has the youth ever resided away from home? YES NO a. a. If yes, specify with whom, where, when and for how long: 3. 56. Has the youth ever been kicked out of their home? YES NO a. a. If yes, specify when, why and for how long: 4. 57. Has the youth ever run away from home? YES NO a. a. If yes, specify when, why and for how long? 58. Has the youth ever been homeless? YES NO *Being homeless means the youth had to stay in a shelter, at different relatives or friends’ homes, or on the street. a. If yes, specify when, why and for how long? 59. Has the transgender identified youth been informed of possible housing arrangements in a dorm that matches their gender identity? YES NO *Youth must be informed that any housing arrangements are subject to administrative approval PHYSICAL HEALTH/MENTAL HEALTH/SEXUAL HEALTH 60. Does the youth have any worries concerning his/her health? YES NO a. If yes, specify: 61. Does the youth have a general medical 62. If yes, is the condition being monitored by a physician? condition? YES NO YES NO If no, skip to question 64. a. Physician Name/Telephone Number:

CASE MANAGEMENT YOUTH & FAMILY INTAKE 63. Is the youth’s physical or social activity impacted by a general medical condition? YES NO a. If yes, specify: 64. Has the youth ever been hospitalized for physical or mental health reasons? YES NO a. If yes, specify when, where, why, and duration: 65. Has the youth taken medication for physical or mental health 66. Does the youth worry that s/he sleeps too much reasons? YES NO or too little? YES NO a. If yes, specify name and the condition for which the a. If yes, specify: medication was prescribed: 67. Does the youth experience frequent headaches or stomach 68. Does the youth worry that s/he is overweight or aches? YES NO underweight? YES NO a. If yes, specify: a. If yes, specify: 69. Has the youth ever thought of hurting him/herself? 70. Has the youth ever attempted hurting YES NO him/herself? YES NO a. If yes, when and by what means: a. If yes, when and by what means: 71. Is the youth thinking of hurting him/herself, presently? 72. Is there anything that triggers the youth’s YES NO thought of hurting him/herself? YES NO a. If yes, what is the youth contemplating and when does s/he a. If yes, specify: project to do something? 73. Does the youth agree to talk to someone if s/he is 74. Has the youth ever been involved in having thoughts of hurting him/herself? YES NO counseling/therapy? YES NO a. If yes, specify when, where, frequency, duration: b. Why did the youth attend counseling/therapy? c. Was the counseling/therapy: voluntary mandated 75. Does the youth smoke cigarettes? YES NO a. If yes, how often: 76. Does the youth consume alcohol? YES NO a. If yes, how often: 77. Does the youth smoke marijuana? YES NO a. If yes, how often and when was the last time: 78. Does the youth consume any other drugs, including 79. At what age did the youth take their first drink prescription drugs? YES NO If no, skip to question 84. or drug? a. If yes, specify: 80. Does the youth ever combine alcohol with other drugs? 81. Does the youth and his/her family or friends YES NO argue about his/her drinking or drug use? YES NO 82. What reaction does the youth have when s/he stops drinking 83. Has the youth ever attended an alcohol or drug or using drugs? treatment program? YES NO a. If yes, when, where and why: *Screening for alcohol or substance use is not a substitute for a full alcohol and substance use assessment. 84. Is the youth allergic to any medication? YES NO 85. Does the youth have any other allergies? a. If yes, specify: YES NO a. If yes, specify: *If the youth identifies as transgender, please ask questions 86-89. If the youth does not identify as transgender please go to question 90. 86. Is the transgender identified youth currently receiving hormone therapy treatment? YES NO a. If yes, where did the youth receive the hormones? Doctor’s prescription Friend Street Other – specify: 87. Has the transgender youth seen a doctor or counselor about their gender identity? YES NO a. If yes, was hormone therapy recommended? YES NO 4 ADMINISTRATION FOR CHILDREN’S SERVICES DIVISION OF YOUTH AND FAMILY JUSTICE

CASE MANAGEMENT YOUTH & FAMILY INTAKE 88. Did a doctor or counselor recommend any other treatments for the youth’s gender identity? YES NO a. If yes, specify: 89. Would the youth like to be referred to a health care service provider that serves other trans youth to discuss trans- specific treatment/services? YES NO a. If yes, specify referral provided to youth: 90. During your life, with who have you had sexual contact? I have never had sexual contact Females Males Females and Males *If the youth’s answer is: ‘I have never had sexual contact’, skip to question 95. 91. Is the youth currently sexually active? YES NO 92. Does the youth practice safer sex? YES NO a. If yes, what kind of protection does the youth use? Male condoms Female condoms Birth control pills Other – Specify: 93. Does the youth suspect or know that they are currently pregnant? YES NO 94. Has the youth ever had sex in exchange for money or had sex in order to have a place to stay at night? YES NO a. If yes, specify: 95. Would you like information and/or resources on STIs, including HIV/AIDS, pregnancy, and other sexual health matters? YES NO a. If yes, specify information and/or resources provided to youth: RELIGIOUS/SPIRITUAL AFFILIATION 96. Does the youth subscribe to any religion or denomination? YES NO a. If yes, specify: 97. Does the youth attend religious services in the community? YES NO a. If yes, specify (type/frequency): 98. Does the youth engage in spiritual practices? YES NO a. If yes, specify: 99. Is the youth interested in attending services or practicing 100. Is the youth interested in speaking with the spiritually while in detention? YES NO Chaplain? YES NO 101. Has the youth ever experienced religious prejudice or discrimination? YES NO a. If yes, specify: 102. Does the youth adhere to any dietary restrictions associated with their religious/spiritual affiliation? YES NO a. If yes, specify: EDUCATION INFORMATION 103. Is the youth attending school? a. If yes, where? b. If no, when was the last time youth YES NO attended school? 104. What is the name of the last school youth 105. What was the last 106. What is the youth’s attended? grade youth completed? anticipated date of graduation? 107. Is the youth enrolled in a special 108. Does the youth have a. If yes, when was the last time education program? YES NO an IEP? YES NO youth was evaluated? b. Was the youth suspended from school before their admission into detention? YES NO a. If yes, when, and what were the terms of the youth’s suspension? 5 ADMINISTRATION FOR CHILDREN’S SERVICES DIVISION OF YOUTH AND FAMILY JUSTICE

CASE MANAGEMENT YOUTH & FAMILY INTAKE c.Does the youth’s family or friends worry about how s/he is d. What is the youth’s favorite subject(s)? doing in school or with their education? YES NO 112. Was the youth involved in any clubs or extra- 113. Does the youth enjoy 114. Does youth get along with curricular activities? YES NO reading? YES NO his/her peers at school? a. If yes, specify: YES NO 115. Did the youth attend a CBO (community-based organization)? YES NO a. Date of youth’s enrollment/discharge in CBO: b. CBO Name: c. Contact Name/Telephone Number: PERSONAL INTERESTS 116. Does the youth have any 117. Does the youth like sports? 118. Does the youth like music? hobbies? YES NO YES NO YES NO a. If yes, specify: a. If yes, specify: a. If yes, specify genre: 119. Does the youth play a musical instrument? 120. Does the youth like 121. Does the youth like to YES NO video games? YES NO draw or paint? YES NO a. If yes, specify: 122. Does the youth have a favorite film or book? 123. What does the youth like to do when s/he is not in school YES NO or during his/her spare time? a. If yes, specify: 124. Does the youth participate in a local recreational program, club or activity? YES NO a. If yes, specify: SOCIAL SUPPORT AND PERSONAL SAFETY 125. Is there someone the youth considers to be a positive influence in their life? YES NO a. If yes, specify name/relationship to youth: 126. Does the youth currently have a girlfriend or boyfriend? YES NO a. If yes, how long has the youth and this individual been together? 127. In his/her current or in any of their past relationships, did the youth’s girlfriend or boyfriend hurt them physically or verbally abuse them? YES NO a. If yes, specify: 128. Has the youth ever felt unsafe because of their sexual orientation (being lesbian, gay, or bisexual)? YES NO If no, skip to question 129. a. If yes, where did the youth feel unsafe? Home Neighborhood School Detention Foster Care Other – Specify: b. Please explain what happened to cause the youth to feel unsafe: 129. Has the youth ever felt unsafe because of their gender identity (being transgender)? YES NO If no, skip to question 130. a. If yes, where did the youth feel unsafe? Home Neighborhood School Detention Foster Care Other – Specify: b. Please explain what happened to cause the youth to feel unsafe: 6 ADMINISTRATION FOR CHILDREN’S SERVICES DIVISION OF YOUTH AND FAMILY JUSTICE

CASE MANAGEMENT YOUTH & FAMILY INTAKE 130. Has the youth received a copy of the LGBTQ “Know Your Rights” palm card? YES NO *If no, a palm card must be issued to the youth prior to the completion of intake. a. If yes, has it been confirmed that the youth’s understands the content of the palm card? YES NO

131. Does the youth have any questions about the palm card as it relates to the ACS LGBTQ policy? YES NO a. If yes, specify:

For LGBTQ identified youth, a confidential email must be sent to the case management supervisor and the Executive Director of Programs that includes a summary of this section. Additionally, LGBTQ youth must be informed that if they do not feel safe at any time they can speak with case management staff, the ombudsperson, or any other staff. 132. Does the youth belong to a gang, set or crew? YES NO a. If yes, which one? 133. Does the youth have any gang-related issues? YES NO a. If yes, specify: 134. Are there any youth in detention with whom the youth has had problems in the community? YES NO a. If yes, whom: 135. Has the youth ever witnessed violence? YES NO a. If yes, specify: 136. Has the youth ever been threatened with a weapon? YES NO a. If yes, specify: 137. Has the youth ever been a victim of violence? YES NO a. If yes, specify: 138. Does the youth ever feel unsafe? YES NO a. If yes, specify: 139. Does the youth every worry for their own safety when around friends/people s/he associates with? YES NO a. If yes, specify: 140. Has the youth ever been forced to have sex when s/he didn’t want to? YES NO a. If yes, specify: 141. Has anyone ever touched the youth’s body in a way that made them feel uncomfortable? YES NO a. If yes, specify: 142. Is there anything staff can help the youth with? YES NO a. If yes, specify:

Check box if the Family Interview section of the Intake form was completed using a hard copy, while the parents/guardians was visiting the youth at the facility. Part 2 – Family Interview FAMILY INFORMATION 1. Mother/Mother (Parent 1): (Last) (First) (MI) 2. Father/Father (Parent 2): (Last) (First) (MI) 3. Legal Guardian: (Last) (First) (MI) 4. Does your child have siblings or relatives currently in detention? YES NO a. If yes, who/relationship to child/name of facility: RESIDENCE INFORMATION 7 ADMINISTRATION FOR CHILDREN’S SERVICES DIVISION OF YOUTH AND FAMILY JUSTICE

CASE MANAGEMENT YOUTH & FAMILY INTAKE 5. If living with a relative, has the youth ever lived away from home? YES NO a. If yes, with whom, where, and for how long? b. What were the circumstances of this arrangement? 6. Have you had any problems with your child at home? YES NO a. If yes, specify: 7. Does your child respond to rules/requests at home? How does your child relate to others at home? YES NO 8. Are there any other important responsible adults involved in your child’s life? YES NO a. If yes, specify name/relationship to child: 9. Does your child share sleeping arrangements? YES NO a. If yes, with whom/age/relationship to child: TELEPHONE CONTACT INFORMATION 10. Would you like your child to call you while s/he is in detention? YES NO a. If yes, what is the best number, day, and time for him/her to reach you? Attach the Authorized Telephone Contact Form VISITING INFORMATION 11. Do you plan to visit your child in 12. Are there other important people in your child’s life that would like detention? YES NO to visit? YES NO *Complete and attach the Authorized Visitors Form LEGAL INFORMATION 13. Will you bring your child a change of 14. Have you already been to court for your child’s case? clothing to wear to court? YES NO YES NO a. If no, why not? 15. Do you plan to attend your child’s future court dates? YES NO a. If no, why not? EDUCATION INFORMATION 16. How often has your child attended school in the last three months? Everyday or almost everyday Most of the time About ½ of the time Less than ½ the time Never or almost never I don’t know 17. Have you ever attended a conference at your child’s 18. When was the last time you attended a conference at school due to his/her behavior? YES NO your child’s school? 19. What are your child’s favorite and/or strongest subjects? 20. Does he/she have any special education needs? YES NO a. If yes, specify: 21. What is your child’s attitude towards school? 22. Does your child express any goals? YES NO a. If yes, what are they? HEALTH/MENTAL HEALTH INFORMATION 23. Does your child exhibit any behavior problems? YES NO a. If, yes specify: 24. Does your child have any medical or psychiatric problems? YES NO a. If yes, specify: 25. Does your child take any medication? YES NO a. If yes, specify type/dosage: b. Name, address and telephone number of the physician treating your child: 26. Has your child ever received mental health counseling? YES NO a. If yes, when and how long?

CASE MANAGEMENT YOUTH & FAMILY INTAKE b. Name, address and telephone number of the provider: 27. Do you receive Medicaid? YES NO a. a. If yes, what is the ID number? 28. Is your family covered by another health insurance plan? YES NO a. If yes, specify plan name: b. Name, address and telephone number of the provider: 29. Is your child allergic to any medication? YES NO a. If yes, specify: 30. Does your child have any seasonal/environmental allergies? YES NO a. If yes, specify: 31. Are there any foods your child is allergic to or cannot eat for religious/cultural reasons? YES NO a. If yes, specify: RELIGIOUS INFORMATION 32. Would you like your child to attend religious services while in detention? YES NO a. If yes, which denomination? 33. Would you like to speak with the Chaplain? YES NO MISCELLANEOUS INFORMATION 34. Is there anything else you would like to tell us about your child? YES NO a. If yes, specify:

Interpretive Summary of Youth’s Needs (If youth responded “yes” to any of the questions highlighted in gray, a description of the youth’s responses must be reflected in this section):

Print Name of Staff Completing Intake Title Date