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: Date:   Full Name of Youth: Gender:   Male Female Date of Birth: Race:   Soc. Sec. # :   Youth's Medical Insurance: Policy #:   Current Medical Needs/Immunization Needs: Current Dietary Needs/Preferences: Current Medications: Please indicate the reasons for making this referral (check all applicable boxes).   Suicide Threats, Ideation, or Attempts   Self-Mutilation   Depression   Anxiety / PTSD   Withdrawal/ Extreme Passivity   Verbal aggression   Physical Aggression   Property Destruction   Runaway   Oppositional/Defiant Behavior   Adjustment failure at previous placement   Hyperactivity and/or Attention Deficits   Impulsive Behaviors/ High Impulsivity   Gang Involvement   Inappropriate sexual conduct   Substance Abuse   Sexual victimization   Criminal History/Activity   Family Issues   Current Behavior Support Needs: Current Protection Needs: Custody/ Contact Information Child Placed By: Contact Person:   Address: Phone: Email:   Supervisor's Name: Phone:   Email: Funded By: Contact Person:   Address: Phone: Email:   Legal Custody is Held By: Relationship:   Address: Phone:   In an Emergency Call: Phone:   Educational Information Eligible for Special Education Services?: Date of Current IEP: Last School Attended: Grade:   Address: Phone:   Local Education Agency: Home School: Address: Phone:   Current Educational Needs: 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: