Date:
Provider Contact Person: Sara Murgel, Admissions Manager
Direct: 406-457-4778 or
IDENTIFYING INFORMATION
Child’s Full name:
______
Last First Middle Social Security #
______
Date of Birth Sex Race
______
Height Weight Religious Preference
______
Eye Color Hair Color Identifying Characteristics/scars
______
Tribal Affiliation Tribal Enrollment Number
Referral Source:
Name
Address
Phone
Child’s current location or placement:
Name Contact Person
Address
Phone
ALL INFORMATION IS CONFIDENTIAL
I. Referring Information:
1. Briefly describe your child’s presenting problems:______
______
______
______
______
______
2. Briefly describe the child’s relevant family/social history:______
______
3. Briefly describe the child’s strengths: ______
______
______
______
______
______
______
3 Discharge Plan ______
______
4. Diagnosis: ______
______
Who made the above diagnosis and when was it established: ______
II. Custody Status:
Who has custody of this child?
Mother ____ Y ____ N
Father ____ Y ____ N
Guardian ____ Y ____ N
Adoptive Mother ____ Y ____ N
Adoptive Father ____ Y ____ N
DPHHS or other social service agency ____ Y ____ N
If yes, is it Permanent ____ Y ___ N
Temporary ____Y ___ N
Name of agency: ______
Have birth parental rights been terminated?
Mother ____ Y ____ N ____ Unknown
Father ____ Y ____ N ____ Unknown
Will family members participate in therapy? ____ Y ____ N
Can this child return Home? Permanently: ____ Y ____ N
For visits only: ____ Y ____ N
Not at all: ____ Y ____ N
Unknown: ____
Does the child have a Guardian ad Litem or CASA advocate? ____ Y ____ N
If yes, name, address and phone number: ______
______
Parent(s):
Birth Mother: ______
Name Phone #
Address: ______
Birth Father: ______
Name Phone #
Address: ______
Step Parent(s): ______
Name Phone #
Address: ______
Step Parent(s): ______
Name Phone #
Address: ______
Adoptive Parent(s): ______
Name Phone #
Address: ______
Adoptive Parent(s): ______
Name Phone #
Address: ______
Legal Guardian: ______
Name Phone #
Address: ______
Sibling(s):
Name: / DOB: / Residence:Other Individuals significant to this child:
Name: / Relationship: / Address: / Phone:III. Education:
Current grade:
Current School:
Resident School District:
District of current enrollment (if different):
Is this child a Special Ed student?
If yes, Label?
Does this child have a Surrogate Parent? ____ Y ____ N
If yes, provide name, address and phone number: ______
______
IV. Juvenile Justice History:
Does this child have history of involvement with the juvenile justice system?
____ Y ____ N ____ Unknown
If yes, please describe:
V. Placement History:
Has the child been placed away from home before? ____ Y ____ N
This section is designed to reflect disruptions or changes in the child’s living situation. Include all agency out of home placements, independent placements, adoptive placements and breakdowns. If the information is available in the social history, make that notation. You do not have to complete this section if the information is available on another document. Make the notation that the document is attached. End with most current:
Name of Provider/Relative/Other / DatesFrom: To: / Reason for Termination:
VI. Abuse/Neglect History:
Does child have a history with Child Protective Services or Social Services? ______(Y/N) If yes, how long ______
Does this child have a history of abuse/neglect? ____ Y ____ N ____ Unknown
If yes, to either or both questions, describe: ______
______
______
VII. Health and Medications:
What are the child’s current medications?
Medication: / Dosage: / Start date: / Symptoms treated with this med:Name of prescribing physician(s): / Phone numbers:
VIII. Other:
Please provide any additional information you feel is pertinent.
______
______
______
______
______
Financial Information:
Person, Agency, County or Insurance company of financial responsibility (please list all that apply):
Does child receive SSI? ____ Y ____ N ____ Unknown
If yes, amount ______
Payee ______
Name Address
______
Signature of Parent/Guardian Date
Completing the Form
ALL INFORMATION IS CONFIDENTIAL - 6 -