Group Care Application Group Care Application Youth Personal InformationYouth 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 Phone NumberPhone Number Email AddressEmail Address Cell PhoneCell Phone AddressAddress Supervisor Email Work PhoneCell PhoneFaxEmergency NumbersMothers Name Add RemoveEmergency NumbersPhone Number: Add RemoveEmergency NumbersFathers Name Add RemoveEmergency NumbersPhone Number Add RemoveEmergency NumbersPerson to Contact in case of an Emergency Add RemoveEmergency NumbersPhone Number Add RemovePerson to Contact in Case of an Emergency Add RemoveEmergency NumbersPhone Number Add RemoveSiblingsName of First Add RemoveSiblingsContact Information Add RemoveSiblingsName of Second Add RemoveSiblingsContact Information Add RemoveSiblingsName of Third Add RemoveSiblingsContact Information Add RemoveSiblingsName of Fourth Add RemoveSiblingsContact Information Add RemoveSiblingsName of Fifth Add RemoveSiblingsContact Information Add RemoveSiblingsName of Sixth Add RemoveSiblingsContact Information 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 Last Monthly Reporting Form 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:Placement Name Placement History:Placement Type Placement History:Dates of Placement Abuse & Neglect History:Placement Name Abuse & Neglect History:Placement Dates Abuse & Neglect History:Placement Type 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 workBehaviorsAggression 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
