<p>Name: Date of Birth: Medicaid Number: </p><p>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. </p><p>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.</p><p>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. </p><p>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)</p><p>Universal Treatment Foster Care and Residential Services Application</p><p>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: </p><p>Date of Application: Click here to enter a date. Date of Services Needed: Click here to enter text.</p><p>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</p><p>Reason for Referral: Hospital Discharge Detention (currently awaiting placement) Higher Level of Care Recommended Lower Level of Care Recommended </p><p>Reason for Referral (including current behaviors) </p><p>Current Emotional/Behavioral Problems (please describe behavior and date of last incident) Abandonment Issues Anxiety Arson </p><p>Alcohol/Drug Abuse Antisocial Behavior Stool/Feces Smearing </p><p>Assaultive (physical) Assaultive (sexual) Assaultive (Verbal) </p><p>Bedwetting Eating Disorder Depression </p><p>Property Destruction Fire Setter Intellectual/Developmental Disability</p><p>Homeless Hyperactive Impulsive </p><p>Lying Low Self-Esteem Loss/Grief Difficulties </p><p>Physical Impairment Attachment Disorder Parent Neglect Issues </p><p>Perception of Reality Phobic Behavior Physical Disability </p><p>Self-Destructive Behavior Sibling Related Difficulty Oppositional </p><p>Social Immaturity Sexually Inappropriate Behavior Stealing Name: Date of Birth: Medicaid Number:</p><p>Suicidal Running Away Truancy </p><p>Unruly/Ungovernable Cruelty to Animals Hygiene/Cleanliness Issues </p><p>Problems with Sleep Gang Related Activity History w/ Weapons </p><p>Trauma History Other Other</p><p>Removed from previous placements? Homicidal Adjudicated for Sexual Offense</p><p>Sexually Aggressive</p><p>Medical Conditions (Past/Present) Lice Bulimia Eczema</p><p>Anemia Anorexia Asthma</p><p>Drug/Alcohol Abuse Measles Hay Fever</p><p>HIV/AIDS Mumps Convulsions</p><p>Sexually Transmitted Disease Chicken Pox Sinus Problems</p><p>Ringworm Sickle Cell Anemia Diabetes</p><p>Tuberculosis Migraine Headaches Hepatitis</p><p>Chronic Urinary/Bowel Problems Rubella TBI</p><p>Allergies: Other: Other: </p><p>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</p><p>Diagnosis and IQ DSM V Diagnosis: ______</p><p>______Name: Date of Birth: Medicaid Number: IQ: Full Scale Verbal Performance Date of Testing: </p><p>School Information Last School Enrolled: District: Grade: </p><p>Special Classes: Special Education Resource Homebound Current IEP Yes No</p><p>LD BED Other: </p><p>History of Truancy: Yes No Suspensions/Expulsions: </p><p>Substance Use History (if applicable) Substance Amount/Frequency Last Use</p><p>Current Medications Medication Dosage/Frequency Purpose Medication Dosage/Frequency Purpose</p><p>Other Agency Involvement (i.e. DJJ, DSS) Contact Person, Phone Number and Agency Reason for Involvement Email address Name: Date of Birth: Medicaid Number:</p><p>______Legal Guardian (Print) Legal guardian (Signature) Date</p><p>______Care Coordinator (Print) Care Coordinator (Signature) Date</p><p>______Referrer/Agency (Print) Referrer (Signature) Date</p>