Methodist Home for Children Referral Form

RESIDENTIAL SERVICES REFERRAL FORM

Service Request Information

Emergency Placement Request? Yes No When needed? Repeat Referral? Yes No Sibling Group Referral? Yes No Service Request(s): Adoptions Foster Care Services Emergency Foster Care Foster Care Respite Group Home Services Therapeutic Foster Care Other

Section A: Child Information

Name: Prefers to be called: Last First Middle Date of Birth: Age: Sex: Race: Social Security Number: Place of Birth (County): State: County of Current Residence: Currently Living With: Biological Parent Relative Foster Family Other (Specify: ) Religious Affiliation, if known: Section B: Reason for Out-of-Home Placement What is the main reason for the child needing out-of-home services? Is this the first time the child has been placed outside of the natural home? Yes No If no, what is the current circumstance leading to this out-of-home placement? Stepping down from a Displaced from current Current foster home cannot Legal guardian requested higher level of care foster home due to behavior meet the child’s needs transfer to new foster home DSS has removed child Legal guardian cannot Other: from current residence manage behaviors Current Placement: Name of Person/Facility:

Previous Placements: (Check all that apply.) Name of Agency Dates of Placement(s) None Campus-based residential program Drug Rehabilitative Program Emergency Shelter Foster Care Group Home Psychiatric Hospital Therapeutic Foster Care Youth Detention Center Youth Development Center Other (Specify: )

C:\\residential admission\referral form 12.12 Current Services: None Case Management Day Treatment Family Therapy Individual Therapy In-Home Services Juvenile Justice Services Physical Therapy Regular Medical Visits Speech Therapy Substance Abuse Treatment Other:

Placement Requirements: (Check all that apply.)

Day Care Few to No Children in Foster Home Foster-to-Adopt Home Foster Parent with specialized skills Gender Specific Foster Home Independent Living Skills Location Request Race Specific Foster Home Stay-at-Home Foster Parents Transportation Needs Dual Parent Home Other

Section C: Referral Source

How agency was found: Referral Source: Name: Agency: Address:

Phone: Fax: Email Address: Current/Previous Worker(s)/Phone: Legal Guardian: Name of Legal Custodian: Phone Number: Mailing Address: Relationship to Child: Name of Contact Person: Phone Number: Email Address:

Biological Family: Biological Mother Name: Phone Number: Current Contact with Child: Yes No Biological Father Name: Phone Number: Current Contact with Child: Yes No

Does DSS have custody of the child in need of services? Yes No If yes, for how long? Adjudication Status: (Check all that apply.) Not Applicable Abuse Neglect Dependency Other

Juvenile Court Delinquency Involvement? Yes No If Yes, Specify Charges: Court Counselor/Phone: Disposition:

Adult Court Involvement? Yes No If Yes, Specify Charges: Convictions? Yes No Pending Next Scheduled Court Appearance?

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Medical: Does the child have allergies? Yes No If Yes, specify allergies: Was the child exposed to drugs or alcohol in utero? Unknown Yes No If Yes, specify: Does the child have any of the following identified needs that require special attention in caring for this child: Physical Medical Developmental Mental Health Functional/Medical Disabilities: Learning Disability FAS MR Hearing/Speech Drug-Exposed Diabetes Seizure Disorder None Other List specific diagnoses, if known or relevant: Medications:

Insurance: None Medicaid Health Choice IPRS ID Number: Home County for Insurance: Mental Health: Home County LME/MCO: Case Phone Number: Email Address: Manager/Agency: IIH Team Lead: Phone Number: Email Address: Day Treatment Phone Number: Email Address: Provider: Psychiatrist: Phone Number: Email Address: Current/Past Phone Number: Email Address: Therapist:

Clinical Disorder: (Check all that apply currently.) None Unknown Adjustment Disorder Anxiety ADHD Bi-polar Disorder Conduct Disorder Depression Dysthymia ODD PTSD Psychotic Disorder Mood Disorder Other

Has the child in need of service been abused? Yes No Physical Abuse Sexually Abuse Both Unknown Has the child in need of service abused others? Yes No Physical Abuse Sexually Abuse Both Unknown Has the child attempted suicide? Yes No Date and description of most recent attempt:

Educational:

Grade: Most Recent School IQ: Full Scale Verbal Performance

Special Needs Educational Classification: Does the child have an IEP? Yes No

Does the child have a history of suspensions? Yes No If yes, has there ever been a long-term suspension? Yes No

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Please provide a description of the youth’s family dynamics. This would include family history, caregiver roles, issues related to domestic violence, sexual abuse, substance abuse, neglect, mental health, etc.:

Description of youth’s strengths and needs related to current and past behavior concerns:

Specific Visitation and Travel Needs:

Section F: Placement Information:

Purpose of Plan/Placement: Explanation:

Expected Length of Stay:

Completed by: Date:

Risk and Protective Factors:

1. Does youth have an adult mentor or teacher that they have regular contact with? 2. Are there any family members involved in his/her care? 3. Does youth show respect for authority? 4. Is youth performing at appropriate grade level and can he/she read at appropriate level? 5. Is the youth’s social behavior age appropriate? 6. Is the youth able to maintain appropriate friendships and get along with peers? 7. Does youth have a positive self-image? 8. Does youth show empathy? 9. Has the youth expressed any life goals? 10. Does the youth show interest in personal development? 11. Is the youth involved in any extracurricular activities? 12. Is the youth involved in any religious activities and attend church? 13. Does the youth have good personal health habits? 14. Does the youth make appropriate decisions and have effective problem solving skills? 15. Does youth demonstrate honesty and take responsibility for actions? 16. Does the youth use illegal substances regularly?

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