Group Care Application Group Care Application Your Personal InformationYour Name First Last Gender Male Female Date of Birth Race Height Weight CID Number Medicaid Number Discharge Plan Permanent Plan Level of Service- Please check the level of service that is being sought for the youth.Community Based Services Out of School Time Independent Living Crisis Stabilization Respite Care Community Reintegration Level of Service- Please check the level of service that is being sought for the youth.QRTP (Group Care) Services Short Term Assessment Group Care–Short Term (30 – 120 days) Group Care–Long Term (6 to 12 months) Tribal Information Enrollment Number Family Services SpecialistName and Office Supervisor EmailWork PhoneCell PhoneFaxJuvenile Corrections AgentJuvenile Corrections AgentNameOfficeEmailPhone NumberSupervisorFax Add RemoveEmergency NumbersMothers NamePhone Number:Fathers NamePhone NumberPerson to Contact in case of an EmergencyPhone NumberPerson child has been living with Add RemoveSiblingsfirst siblingsecond siblingthird siblingfourth siblingfifth siblingsixth siblingseventh siblingeighth sibling Add RemoveMaterials to be Included Removal/Commitment Order giving Custody to the State Latest Report to the Court Child Case Plan Copy of the Social Security Card Copy of Birth Certificate Copy of Most Recent Psychiatric Evaluation Copy of Most Recent Psychological Evaluation Copy of Discharge Summaries From Prior Placements Other Services Provided Speech Language Counseling by School Behavior Issues School Record Current IEP Report Cards Medical Records EPSDT, Immunization Records, TB Test, Dental, Vision, Hearing Medical RecordsPlease list name and address of each medical provider Medical RecordsDates of each record: Please list as 10/25/24-flu shot, 9/8/24-TB test, etc Dates Of Last:TB Test: Physical Exam:Physical Exam: Vision Test:Vision Test: Dental Visit:Dental Visit: Hearing Test:Hearing Test: List Allergies Current Medications: Name & Phone Number of:Child's Doctor: Child's Dentist:Child's Dentist: Placement History:Abuse & Neglect History: Drug / Alcohol History:Child: Drug / Alcohol History:Parents: Fetal Alcohol Spectrum Disorder Information: Who Can Child Have Contact With:Name Should the person above be invited to meetings related to the student?Relation to Student Yes No Should the person above be invited to meetings related to the student?Monitored Yes No Who Can Child Have Contact With:Name Should the person above be invited to meetings related to the student?Relation to Student Yes No Should the person above be invited to meetings related to the student?Monitored Yes No Who Can Child Have Contact With:Name Should the person above be invited to meetings related to the student?Relation to Student Yes No Should the person above be invited to meetings related to the student?Monitored Yes No No Contact ListPlease provide name and relation to the studentDiscipline used in last Placement:Please provide what has worked and then was did not workLast Monthly Reporting Form: First Choice Second Choice Third Choice BehaviorsAggression Yes No If yes, please describe below: BehaviorsFire Starter Yes No If yes, please describe below: BehaviorsRun Away Yes No If yes, please describe below: BehaviorsAlcohol Use Yes No If yes, please describe below: BehaviorsSexual Abuse Yes No If yes, please describe below: BehaviorsSuicidal Ideation Yes No If yes, please describe below: BehaviorsHuffing Yes No If yes, please describe below: BehaviorsCar Theft Yes No If yes, please describe below: BehaviorsSexual Behaviors Yes No If yes, please describe below: BehaviorsSelf Harm Yes No If yes, please describe below: BehaviorsDrug Use Yes No If yes, please describe below: BehaviorsDrug Use Yes No If yes, please describe below: BehaviorsSexually Active Yes No If yes, please describe below: If Sexual Behaviors category is marked “yes”:Was sexual offender treatment recommended, and if so has the child completed? Yes No If yes, where was sexual offender treatment completed at? Please list any other behaviors that the child may need services for:Additional information that would be helpful to know to provide appropriate care for the child:Reasons For Placement / Desired Treatment Outcome:Discharge Plan. Please indicate in as much detail as possible what the discharge plan is for this student upon completion of this program:Have Parents/Immediate family been notified of this possible placement? If No, please explain:In order to maintain safety and security within the facility it may be necessary to utilize seclusion and/or restraint at times. The guidelines for the use of seclusion/restraint are enforced through licensing regulations.Is the use of seclusion and restraint approved for this referral? Yes No Name of Person Completing This Form Untitled
