Admission Application

Agency requesting placement *

Other

County

Placing officer *

Phone *

Email address *

Placement type *

Anticipated length of stay *

Anticipated placement date *

Youth name *

DOB *

Age *

Gender *

Male

Female

Ethnicity *

Reason for placement *

Aggression *

Sexually Maladaptive *

Self-harm *

Suicide/homicide ideations *

Substance Use *

If yes to any of the above, please describe *

History: Please include details such as last known incidents, who aggression is towards, specific substances, etc.

Diagnosis *

Medications: List medication and what it is for *

Cans score *

IEP *

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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