APPLICATION FOR INTERMOUNTAIN – FAMILY-BASED SERVICES HOME SUPPORT SERVICES

Date:

REFFERAL SOURCE INFORMATION

Name: ______Agency:______Address:______City:______State:______Zip:______Phone Number: Email:______

CHILD INFORMATION

Name: Date of Birth: Age:______Social Security #: Medicaid #: ______Insurance Company Group ID or #: Gender: Ethnicity: Allergies:______Child’s current location or placement:

Is the child (check those that apply): o Medicaid Eligible o In Foster Care o Adopted If yes, date finalized:______Agency:______

COMMUNITY SERVICE PROVIDERS (check those that apply & indicate name & phone number of service professional):

o Outpatient Therapy name:______o CSCT Services name:______o Day Treatment name:______o Residential or Short-Term Treatment name:______o Partial Hospitalization name:______o Child & Family Services name:______o Court Appointed Special Advocate (CASA) name:______o I-Home Wraparound Facilitator name:______o Case Manager name:______o Juvenile Probation name:______o Youth Court / Corrections name:______ALL INFORMATION IS CONFIDENTIAL - 1 - o Other name:______

GUARDIAN / FAMILY (Responsible Party) INFORMATION

Name & Relationship to Child Address:______City:______State:______Zip:______Phone Number: Email:______

Sibling(s) Name DOB Residence

______

Legal Custodian: Custody Status:

EDUCATIONAL INFORMATION

Name of School Currently Attending: ______Contact Person & Phone Number: ______Grade: Does the child have an IEP or other educational accommodations? ______

TRIBAL AFFILIATION / AGENCY

Tribal Affiliation: Tribal Enrollment #: ______Contact Person & Phone Number: ______

REFERRAL INFORMATION

Briefly describe child's present problems/behaviors: ______

Briefly describe the child’s strengths:

______

What are the current needs of this child or family at this time:

Why are you referring the child to Intermountain at this time?

ALL INFORMATION IS CONFIDENTIAL - 2 - DSM IV -TR DIAGNOSIS:

Axis I Axis II Axis III Axis IV Axis V (GAF)___

Medications and length of time on them:

Prescribing Physician: ______Phone:

ADDITIONAL INFORMATION YOU WOULD LIKE US TO KNOW: ______

______

Legal Guardian Signature (application not valid until signed) Date

Return Application To:

Family Based Services – Intermountain Attention: Kelly Zimmerman 3240 Dredge Drive Helena, MT 59602 FAX: (406) 442-7949 (406) 457-4842 [email protected]

ALL INFORMATION IS CONFIDENTIAL - 3 -