Admissions Placement Form

Referral Source Name *
Referral Source Name
Phone *
Phone
Client's Name *
Client's Name
Client's Date of Birth *
Client's Date of Birth
Please specify gender if "Other".
Program *
Please check the box of the program(s) in which you are interested.
Please specify program type if "Other".
Does the client have an Individualized Education Plan?
Current Behavioral Concerns *
Please check all behavioral concerns that apply to the client.
Trauma *
Please check all trauma areas that apply to the client.
Please include facility names and treatment dates, if applicable.
If client is currently placed in a facility, please include facility name and dates of placement.
Please include a brief description of why you are seeking services for this client, and please speak to why a higher level of care is needed.
Please speak to the client's family dynamics and engagement of viable family members.
Please include charges, drugs of choice, and gang affiliation if applicable.
Please speak to the client's strengths and to what approaches the client responds.
Please include client's most recent DSM diagnosis and/or DSM code.
Please include notable medical concerns and allergies.
Who Holds Educational Rights? *
Who Holds Educational Rights?
e.g. in-school suspension, detention, office referral, etc.
Treatment Funding *
Must select one or more.
Please include Medicaid or insurance number, name of payer agency, authorization number, and/or explanation of "other" if selected above.
Primary Caregiver *
Primary Caregiver
Please include Primary Caregiver's relationship to the client.
Caregiver's Phone Number *
Caregiver's Phone Number
Caregiver's Address
Caregiver's Address
If Not, Who is Legal Guardian?
If Not, Who is Legal Guardian?
Please provide names, phone numbers, and e-mail addresses for other stakeholders (caseworker, probation, GAL, and other professionals).