I certify that I have the authority to make application on behalf of this youth and that all information furnished is complete and accurate to the best of my knowledge:

Relationship to Youth: Date:   Full Name of Youth* Gender:   Male Female (Include Middle Name): Date of Birth:    Race: Soc. Sec. # :   Youth’s Primary Medical Insurance: Policy #:           Youth’s Secondary Medical Insurance: Policy #:   If youth has Medicaid, it is an HMO, FAMIS, Va Premier, Optima or Straight?     Party Responsible for Co-Pays and unpaid bills?     Past and Present Physical Health Needs     Immunization Needs: Allergies (drug, food, etc.) and Reaction       Current Dietary Needs/Preferences: Current Medications:   Please indicate the reasons for making this referral (check all applicable boxes).   Suicide Threats, Ideation, or Attempts  Adjustment failure at previous placement   Self-Mutilation  Hyperactivity and/or Attention Deficits   Depression  Impulsive Behaviors/ High Impulsivity  Anxiety / PTSD  Gang Involvement   Withdrawal/ Extreme Passivity  Inappropriate sexual conduct  Anger Control Issues  Substance Abuse  Verbal aggression  Sexual victimization   Physical Aggression  Criminal History/Activity  Property Destruction  Family Issues   Runaway  Other Oppositional/Defiant Behavior     Services needed based on the Mental Health, Emotional and Psychological needs (e.g. individual therapy, family therapy, AA/NA, Psychiatric monitoring, etc.):   Current Behavior Support Needs (successful interventions, triggers, etc.):   Current Protection Needs (risk to other residents and others in program):       If Youth has past or present substance use/abuse, please describe including naming substances:       Identifying Characteristics (such as tattoos, piercing or scars):   Custody/ Contact Information Legal Custody Held By: Contact Person:   Address:       Phone: Fax:     Email: *     Supervisor's Name: Phone:   Email:     In an Emergency Call: Phone:   Funded By: Contact Person:   Address:       Phone: Fax:   Email:   Funding Approved on:   Other Parties Involved: Relationship:   Address:       Phone:  Fax:     Email:       Group Home, Independent Living and Therapeutic Foster Care only: Visiting Arrangements (a)= on campus only (b)= on/off campus visits (c)= overnight visits: Per legal guardian if child is accepted who can visit:   Per legal guardian if child is accepted who cannot visit:   Status of Biological Parents:     Discharge Planning:   Discharge goal from VHBG:       Concurrent discharge goal:       Projected discharge date from VHBG: Oasis #   Next FAPT Date / Time: Next Court Date / Time:   Court Involvement:         Probation Officer:             Address:         Phone: Fax:   Email:     Educational Information Eligible for Special Education Services?:     If Yes, Date of Current IEP: and Disability:   Last School Attended:     Address:     Phone:  Grade at time of referral:     Local Education Agency:     Home School:     Address:   Phone:   LEA Case Manager:       Phone: Fax:   Email:       Current Educational Needs:       Last DSM Diagnosis: By Whom: Date:   Axis I:   Axis II:   Axis III:   Axis IV:   Axis V:   Required Data   Copy of FAPT services Plan No record available Comment   Most recent school transcript No record available Comment       Social History No record available Comment   Current IEP No record available Comment       Psychological Evaluation/Assessment of Functioning No record available Comment   Educational Evaluations No record available Comment       Copy of Insurance Card No record available Comment   Educational Records No record available Comment       Immunization Record No record available Comment   Physical Examination(date of last visit, Dr. name & phone #) No record available Comment       Copy of Birth Certificate No record available Comment   Dental Examination No record available Comment       Copy of Social Security Card No record available Comment