Residential Online Referrals

 

Residential Referral Form
 
**All information contained in this placement referral is strictly confidential**

Child Demographics
Date* Calendar
Program Requested*  
Child First Name*
Child Middle Name*
Child Last Name*
DOB* Calendar
Age*
Race*  
Tribal Affiliation*
Identifies As:
Preferred Pronouns
Placement Type*  
Youth's Current Residence/Placement*
Narrative Regarding the Placement*
Referral Information
*A copy of the hold and placement agreement will be required upon placement.*
Name of Person Making Referral*
Your Cell Phone Number*
()-ext
Enter Int'l Number
Your Direct Phone Number
()-ext
Enter Int'l Number
Fax Number
()-ext
Enter Int'l Number
Your Email Address*
Your Mailing Address*
Relationship to the Youth*
Other Professionals Working with this Child
Please include: Agency, Worker's Name, Phone/Email and whether or not they are involved in the child's treatment.
Please describe why you are making this referral, describe the goals of treatment, and what is the permanency/post-placement plan:*
Mother's Information
Mother's Full Name*
Mother's DOB Calendar
Mother's Address
Mother's Phone Number
()-ext
Enter Int'l Number
Mother's Email
Does She Have Custody*
Mother TPR  
Restrictions on Mother's Involvement
Sibling Information
Siblings*
Please include: Full Name, Age, Gender and if there are any contact restrictions.
Father's Information
Father's Full Name*
Father's DOB Calendar
Father's Address
Father's Phone Number
()-ext
Enter Int'l Number
Father's Email
Does He Have Custody*
Father TPR  
Restrictions on Father's Involvement
History of Services Delivered
Has the youth received previous services from NHCFS in either Bemidji or Duluth locations?*
If yes, please provide more information in the box* *
Outpatient Services (therapy, day treatment, partial hospitalization, etc)*
Please include: Name of Agency, Dates of Service and Result.
Residential/Inpatient Services (including hospitalizations)*
Please include: Name of Agency, Dates of Service and Result.
Delinquency History
Does the youth have a delinquency history?*
Please document the youth's previous offenses in the box* *
Please include: Year, Offense and Outcome for each offense.
Medical Information
Name of Current Pharmacy
Pharmacy Phone Number
()-ext
Enter Int'l Number
Medication List
Please include: Name of Medication(s), Strength/mg, Frequency Taken and Name of Current Prescriber/Clinic
Allergy Information
Please list all known allergies along with the youth's reaction to them.
Name of Primary Physician
Name of Primary Dentist
History
History of Neglect*
History of Physical Abuse*
History of Emotional/Psychological Abuse*
History of Sexual Abuse*
If yes to any of the above questions regarding neglect or abuse, please give more information and list perpetrators in the box.* *
Is there a history of cutting or self-injurious behavior (SIB)?*
Is there a history of suicidal ideation?*
If yes to Suicidal Ideation, please enter number of attempts* *
FASD*  
If diagnosed, name of Diagnostic Clinic/Professional* *
History of Sexual Behaviors/Talk*
If yes, please describe* *
Has the youth successfully completed treatment to address the sexual behaviors/talk?* *
Cruelty to Animals*
Verbally Abusive to Others*
Physically Abusive to Others*
Gang Involvement*
Difficulties with Peer Relationships*
History of Running Away*
If yes to Running Away, please provide further details* *
Please include: Number of Occurrences, Length of Time Away, Date(s) of Occurrences and Where the Youth Goes When on Run
Does the youth have a history of being homeless?*
History 2
Does the youth currently use recreational or street drugs?*
Does the youth currently use alcohol?*
Does the youth have an eating disorder or suspected eating disorder?*
Does the youth have grief or loss suffering?*
If yes, describe the loss and month/season it occurred* *
Does the youth have difficulty with parental relationships?*
Lying or Cheating Concerns*
Current Concerns/History of Enuresis or Encopresis*
Does the youth have vision or hearing loss?*
Is there a history or concern of truancy or lack of academic motivation?*
Does the youth have identity issues?*
Does the youth have a history of Sexual Exploitation?*
Is there a current diagnostic/functional assessment*
If yes, please provide the date of completion and provider/agency* *
Current School Attending and Grade*
Is the youth on an IEP?*
Strengths of youth/family*
Any physical restrictions for the youth*
Can the developmental, educational, cultural and mental health needs of the youth be met by the Program?*
Additional Services
Additional comments or requests pertaining to the following question should be added into the box below
Please select any additional services requested during placement
 
Additional Information* *
Primary Insurance Information
Name of Primary Insurance*
Is this a PMAP?*
Has the placement been approved by the PMAP?
Have you requested a faxed confirmation?
Address of Primary Insurance
Primary Insurance Phone
()-ext
Enter Int'l Number
Name of Insured
Relationship to Youth
Insured DOB Calendar
Insured ID Number
Group Number
Name of Insured Employer
Secondary Insurance Information
Is there Secondary Insurance?
Name of Secondary Insurance
Address of Secondary Insurance
Secondary Insurance Phone
()-ext
Enter Int'l Number
Name of Insured (Secondary)
Relationship to Youth (Secondary)
Insured DOB (Secondary) Calendar
Insured ID Number (Secondary)
Group Number (Secondary)
Name of Insured Employer (Secondary)
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