Name: Date of Birth: Medicaid Number

Name: Date of Birth: Medicaid Number:

Instructions for Completing The Universal Application The Universal Application offers a comprehensive clinical review of a consumer’s needs without having to complete several agency specific applications.

Instructions for completing the Universal Application are listed below. 1. The Universal Application should be completed in full by the referring agent. Please answer each question. Do not leave questions or sections blank. If not applicable, please write “N/A”. Applications will be returned to referring party if deemed incomplete. 2. Please do not write “see attached” in sections requiring specific detail. If you have a document that provides greater detail, please reference the document name, date and page number at the end of your explanation. (E.g. Psychological Evaluation, 2-2-09, Page 3) 3. Please have Legal Guardian sign Universal Application.

Referral Checklist In 2nd column please indicate each item that is being attached to this packet. Please comment on reasons items are missing or items that will be sent at later time.

Universal Application Person Centered Plan / Signature Page Discharge Summaries from Hospitalizations / Previous Treatment Consent to exchange information School Records/ IEP DSS records (if applicable) DJJ records (if applicable) Psychological Testing Sexually Aggressive Youth Evaluation / Sex Offender Specific Evaluation/ Psychosexual Risk Evaluation Immunization Records Birth Certificate Copy of Medicaid/ Insurance Cards Psychiatric evaluations Diagnostic Assessment / Comprehensive Clinical Assessment (CCA) or any other assessment completed Treatment Authorization Request Court/Custody Orders Social Security Card (copy)

Universal Treatment Foster Care and Residential Services Application

Consumer’s Name: Date of Birth: Age: Consumer’s Address: Consumer’s Phone Number: Legal Guardian: Relationship: Guardian’s Address: Guardian’s Phone Number: Final 1/15/16 1 Name: Date of Birth: Medicaid Number: Parental Rights Terminated?: Adopted? Date of Adoption?: Child & Family Team contact name and number Alliance Care Coordinator name and number: Medicaid?: Private Insurance Information (include type, policy # and insured’s name): Certificate of Need? (if seeking PRTF placement): Primary Care Physician name and #: Dentist name and #: Therapist name and #: Psychiatrist name and #: Name and # of current Prescriber:

Date of Application: Click here to enter a date. Date of Services Needed: Click here to enter text.

Type of Referral Requested: Level I Therapeutic Foster Care Level II-Family Type Therapeutic Foster Care Level II-Program Type TFC Group Home Level III Group Home Level IV Group Home PRTF Respite

Reason for Referral: Hospital Discharge Detention (currently awaiting placement) Higher Level of Care Recommended Lower Level of Care Recommended

Reason for Referral (including current behaviors)

Current Emotional/Behavioral Problems (please describe behavior and date of last incident) Abandonment Issues Anxiety Arson

Alcohol/Drug Abuse Antisocial Behavior Stool/Feces Smearing

Assaultive (physical) Assaultive (sexual) Assaultive (Verbal)

Bedwetting Eating Disorder Depression

Property Destruction Fire Setter Intellectual/Developmental Disability

Homeless Hyperactive Impulsive

Lying Low Self-Esteem Loss/Grief Difficulties

Physical Impairment Attachment Disorder Parent Neglect Issues

Perception of Reality Phobic Behavior Physical Disability

Self-Destructive Behavior Sibling Related Difficulty Oppositional

Social Immaturity Sexually Inappropriate Behavior Stealing Name: Date of Birth: Medicaid Number:

Suicidal Running Away Truancy

Unruly/Ungovernable Cruelty to Animals Hygiene/Cleanliness Issues

Problems with Sleep Gang Related Activity History w/ Weapons

Trauma History Other Other

Removed from previous placements? Homicidal Adjudicated for Sexual Offense

Sexually Aggressive

Medical Conditions (Past/Present) Lice Bulimia Eczema

Anemia Anorexia Asthma

Drug/Alcohol Abuse Measles Hay Fever

HIV/AIDS Mumps Convulsions

Sexually Transmitted Disease Chicken Pox Sinus Problems

Ringworm Sickle Cell Anemia Diabetes

Tuberculosis Migraine Headaches Hepatitis

Chronic Urinary/Bowel Problems Rubella TBI

Allergies: Other: Other:

History (i.e. trauma, medical, legal, include any family history of mental illness or substance abuse. Include treatment history. What lower levels of care have been tried? What interventions have been used in the last 30 days? Where is the child currently? Include agency and contact name and number. When was the last Child & Family Team meeting?) – Please attach supporting documentation

Diagnosis and IQ DSM V Diagnosis: ______

______Name: Date of Birth: Medicaid Number: IQ: Full Scale Verbal Performance Date of Testing:

School Information Last School Enrolled: District: Grade:

Special Classes: Special Education Resource Homebound Current IEP Yes No

LD BED Other:

History of Truancy: Yes No Suspensions/Expulsions:

Substance Use History (if applicable) Substance Amount/Frequency Last Use

Current Medications Medication Dosage/Frequency Purpose Medication Dosage/Frequency Purpose

Other Agency Involvement (i.e. DJJ, DSS) Contact Person, Phone Number and Agency Reason for Involvement Email address Name: Date of Birth: Medicaid Number:

______Legal Guardian (Print) Legal guardian (Signature) Date

______Care Coordinator (Print) Care Coordinator (Signature) Date

______Referrer/Agency (Print) Referrer (Signature) Date