subject_line
Admission Application
Agency requesting placement
*
Probation
DCS
Choices
Other
Other
County
Placing officer
*
Phone
*
Email address
*
Placement type
*
Emergency
Residential/Long-term
Anticipated length of stay
*
Anticipated placement date
*
Youth name
*
DOB
*
Age
*
12
13
14
15
16
17
18
19
20
Gender
*
Male
Female
Ethnicity
*
Caucasion
African American
Native American/Alaskan Native
Pacific Islander
Asian
Native Hawaiian
Reason for placement
*
Sexually Maladaptive
*
Yes
No
History: Please include details such as last known incidents, who aggression is towards, specific substances, etc.
Self-harm, suicide ideation or attempt
*
Agression
*
Substance abuse
*
Other notable behaviors
*
Diagnosis
*
Medications: List medication and what it is for
*
Cans score
*
IEP
*
Yes
No
School/ education plan & grade
*
Services in place/ will be put in place
*
Attach: Recent psych eval, monthly progress notes, discharge reports, IEP and any other supporting documents
*
Placing Agent Signature
*
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