<p> APPLICATION FOR INTERMOUNTAIN – FAMILY-BASED SERVICES HOME SUPPORT SERVICES</p><p>Date: </p><p>REFFERAL SOURCE INFORMATION</p><p>Name: ______Agency:______Address:______City:______State:______Zip:______Phone Number: Email:______</p><p>CHILD INFORMATION</p><p>Name: Date of Birth: Age:______Social Security #: Medicaid #: ______Insurance Company Group ID or #: Gender: Ethnicity: Allergies:______Child’s current location or placement: </p><p>Is the child (check those that apply): o Medicaid Eligible o In Foster Care o Adopted If yes, date finalized:______Agency:______</p><p>COMMUNITY SERVICE PROVIDERS (check those that apply & indicate name & phone number of service professional):</p><p> 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:______</p><p>GUARDIAN / FAMILY (Responsible Party) INFORMATION</p><p>Name & Relationship to Child Address:______City:______State:______Zip:______Phone Number: Email:______</p><p>Sibling(s) Name DOB Residence</p><p>______</p><p>Legal Custodian: Custody Status: </p><p>EDUCATIONAL INFORMATION</p><p>Name of School Currently Attending: ______Contact Person & Phone Number: ______Grade: Does the child have an IEP or other educational accommodations? ______</p><p>TRIBAL AFFILIATION / AGENCY</p><p>Tribal Affiliation: Tribal Enrollment #: ______Contact Person & Phone Number: ______</p><p>REFERRAL INFORMATION</p><p>Briefly describe child's present problems/behaviors: ______</p><p>Briefly describe the child’s strengths: </p><p>______</p><p>What are the current needs of this child or family at this time: </p><p>Why are you referring the child to Intermountain at this time? </p><p>ALL INFORMATION IS CONFIDENTIAL - 2 - DSM IV -TR DIAGNOSIS: </p><p>Axis I Axis II Axis III Axis IV Axis V (GAF)___ </p><p>Medications and length of time on them: </p><p>Prescribing Physician: ______Phone: </p><p>ADDITIONAL INFORMATION YOU WOULD LIKE US TO KNOW: ______</p><p>______</p><p>Legal Guardian Signature (application not valid until signed) Date</p><p>Return Application To:</p><p>Family Based Services – Intermountain Attention: Kelly Zimmerman 3240 Dredge Drive Helena, MT 59602 FAX: (406) 442-7949 (406) 457-4842 [email protected]</p><p>ALL INFORMATION IS CONFIDENTIAL - 3 -</p>