Residential Online Referrals
Residential Referral Form
**All information contained in this placement referral is strictly confidential**
Child Demographics
Date
*
Program Requested
*
35-Day Evaluation
Boys Program
Boys Teens in Transition
Girls Residential Treatment
Residential Treatment Cottage
Secure Detention
SEY Program
Stabilization/90 Day Intensive Treatment
Child First Name
*
Child Middle Name
*
Child Last Name
*
DOB
*
Age
*
Race
*
White/Caucasian
American Indian/Alaska Native
Black/African American
Asian
Hispanic/Latino
Native Hawaiian/Pacific Islander
Multiracial/Other
No Preference
Unknown
Tribal Affiliation
*
Identifies As:
Preferred Pronouns
Placement Type
*
Court Order
Social Service
Voluntary
Other
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
*
Enter International
Your Direct Phone Number
Enter International
Fax Number
Enter International
Your Email Address
*
Your Mailing Address
*
Relationship to the Youth
*
Other Professionals Working with this Child
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
Mother's Address
Mother's Phone Number
Enter International
Mother's Email
Does She Have Custody
*
Yes
No
Mother TPR
Yes
No
In Process
Restrictions on Mother's Involvement
Sibling Information
Siblings
*
Father's Information
Father's Full Name
*
Father's DOB
Father's Address
Father's Phone Number
Enter International
Father's Email
Does He Have Custody
*
Yes
No
Father TPR
Yes
No
In Process
Restrictions on Father's Involvement
History of Services Delivered
Has the youth received previous services from NHCFS in either Bemidji or Duluth locations?
*
Yes
No
If yes, please provide more information in the box
**
Outpatient Services (therapy, day treatment, partial hospitalization, etc)
*
Residential/Inpatient Services (including hospitalizations)
*
Delinquency History
Does the youth have a delinquency history?
*
Yes
No
Please document the youth's previous offenses in the box
**
Medical Information
Name of Current Pharmacy
Pharmacy Phone Number
Enter International
Medication List
Allergy Information
Name of Primary Physician
Name of Primary Dentist
History
History of Neglect
*
Yes
No
History of Physical Abuse
*
Yes
No
History of Emotional/Psychological Abuse
*
Yes
No
History of Sexual Abuse
*
Yes
No
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)?
*
Yes
No
Is there a history of suicidal ideation?
*
Yes
No
If yes to Suicidal Ideation, please enter number of attempts
**
FASD
*
Has FASD Diagnosis
None
Suspected
If diagnosed, name of Diagnostic Clinic/Professional
**
History of Sexual Behaviors/Talk
*
Yes
No
If yes, please describe
**
Has the youth successfully completed treatment to address the sexual behaviors/talk?
**
Yes
No
Cruelty to Animals
*
Yes
No
Verbally Abusive to Others
*
Yes
No
Physically Abusive to Others
*
Yes
No
Gang Involvement
*
Yes
No
Difficulties with Peer Relationships
*
Yes
No
History of Running Away
*
Yes
No
If yes to Running Away, please provide further details
**
Does the youth have a history of being homeless?
*
Yes
No
History 2
Does the youth currently use recreational or street drugs?
*
Yes
No
Does the youth currently use alcohol?
*
Yes
No
Does the youth have an eating disorder or suspected eating disorder?
*
Yes
No
Does the youth have grief or loss suffering?
*
Yes
No
If yes, describe the loss and month/season it occurred
**
Does the youth have difficulty with parental relationships?
*
Yes
No
Lying or Cheating Concerns
*
Yes
No
Current Concerns/History of Enuresis or Encopresis
*
Yes
No
Does the youth have vision or hearing loss?
*
Yes
No
Is there a history or concern of truancy or lack of academic motivation?
*
Yes
No
Does the youth have identity issues?
*
Yes
No
Does the youth have a history of Sexual Exploitation?
*
Yes
No
Is there a current diagnostic/functional assessment
*
Yes
No
If yes, please provide the date of completion and provider/agency
**
Current School Attending and Grade
*
Is the youth on an IEP?
*
Yes
No
Strengths of youth/family
*
Any physical restrictions for the youth
*
Yes
No
Can the developmental, educational, cultural and mental health needs of the youth be met by the Program?
*
Yes
No
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
Psychological Evaluation
Individual Therapy
Family Therapy
SUD Comp Assessment
Medication Management
Religious/Cultural Needs
Specific Medical/Dental Care
Other
Additional Information
**
Primary Insurance Information
Name of Primary Insurance
*
Is this a PMAP?
*
Yes
No
Has the placement been approved by the PMAP?
Yes
No
Have you requested a faxed confirmation?
Yes
No
Address of Primary Insurance
Primary Insurance Phone
Enter International
Name of Insured
Relationship to Youth
Insured DOB
Insured ID Number
Group Number
Name of Insured Employer
Secondary Insurance Information
Is there Secondary Insurance?
Yes
No
Name of Secondary Insurance
Address of Secondary Insurance
Secondary Insurance Phone
Enter International
Name of Insured (Secondary)
Relationship to Youth (Secondary)
Insured DOB (Secondary)
Insured ID Number (Secondary)
Group Number (Secondary)
Name of Insured Employer (Secondary)
Submit
