Please mail,fax or email completed form, along with pertinent information, to the attention of: Alex Hawk, 150 Glenwood Lane, Birmingham, AL 35242, fax #205-795-3290, or . Not following these instructions may cause delays in the processing of your application.
RESIDENTIAL
REFERRAL
Referral Date: ______
Name of Person Referring:______Phone #: ______
Active/Follow Up Case Worker:______Phone#:______
Date Placement Needed: ______Current Placement______
Region: ______Case# ______
Funding source (circle one) DHR/724 DMHMULTI-NEEDS
Has funding been approved? (Circle one) YES NO
Child’s Name: ______Race ______Sex ______DOB: ______
Height ______Weight ______Religious Preference ______
Social Security #: ______
Medicaid # or Private Insurance ID#______
Reason for Referral:Placement upon Discharge:
_____ Assessment ____ Return to Parents
_____ Reunification____ Placed with Relatives
_____ Transition ____ Therapeutic Foster Care
_____ Respite ____ Adoption
_____ Crisis Planning ____ Independent Living
_____ Long term residential ____ Residential Treatment Facility
____ Uncertain
____ Other: ______
What are the primary things that you would like the team to address?
______
Child’s Strengths:
______
Family’s Strengths:
______
History with DHR:
Is this the child’s first time in DHR Care? Yes No (list previous experiences) ______
Why is the child in care?
______
DHR Worker: ______Phone: ______
DHR Supervisor: ______Phone: ______
Date of last Individual Service Plan (ISP) ______
Date of last EPSDT (physical): ______
Previous Placements:
Placement DateDischarge DateName of PlacementReason for Discharge
______
______
______
______
______
Family Information:
Mother: ______Father: ______
Date of Birth: ______Date of Birth: ______
Address: ______Address: ______
______
Home Phone: ______Home Phone: ______
Employer: ______Employer: ______
Occupation: ______Occupation: ______
Work Phone: ______Work Phone: ______
Cell Phone: ______Cell Phone: ______
Siblings
NameDOB/Age SexRelationIn Household? (If No-Where)
______
______
______
Significant Others:(Relatives, clergy, neighbors, teachers, probation officers, therapist, friends, etc.)
Name: ______Relationship: ______
Address: ______
Phone: ______
Name: ______Relationship: ______
Address: ______
Phone: ______
Educational Information:
School Currently Attending: ______
Address: ______
Grade Currently Enrolled In: ______
Has this child had any suspensions? Yes No If yes, how many? ______
Will the child be returning to this school?YesNoReason: ______
Special Education Placement?YesNoIf yes: LD EC MR Other
(Child must be deemed eligible for special education services prior to admission.)
Date of Last IEP? ______FSIQ______
****Glenwood school is only certified educationally through the 8th grade
Probation:
Is the child on probation? Yes No
Charges? ______
Probation Officer: ______
Last Court Date: ______
Next Court Date: ______
Judge: ______
GAL: ______
Behavioral History:
_____Impulsive_____Bullies
_____Verbally Assaultive_____ Defiant
_____Fights with Siblings_____ Fights with Caretakers
_____Use of Weapons_____ Gang Affiliation
_____Homicidal_____Stealing
_____Destruction of Property_____Use of Drugs
_____Sexually Reactive_____Sexually Active
_____Forced someone into sex_____Cruelty to animals
_____Fire setting_____Runaway
_____Truancy_____Lying
_____Excessive Worry_____Self-Abusive
_____Suicidal_____Use of Alcohol
_____Encopresis (soiling)_____Enuresis (Bed Wetting)
Significant Traumas:
Sexual Abuse:YesNoWhen ______By Whom ______
Physical AbuseYesNoWhen ______By Whom ______
NeglectYesNoWhen ______By Whom ______
DeathsYesNoWhen ______Who ______
OtherWhen ______Who ______
Family Medical History:
Please list any medical conditions of family members: ______
______
Please list any psychiatric conditions of family members: ______
______
Please list substance abuse problems within the family (include child’s exposure to substances): ______
______
Medical Information:
Are immunizations up to date?YesNo
Date of last Physical Exam: ______
Name of Physician: ______
Name of Psychiatrist: ______
Significant Medical Conditions:
____ HIV/AIDS_____ Allergies_____ Anemia_____ Asthma
____ Cancer_____ Depression_____ Diabetes_____ Eating D/O
____ Encopresis_____ Enuresis_____ Headaches_____ Head Injury
____ Hyperactivity_____ Hearing_____ Pregnancy_____ Blood Pressure
____ Seizures_____ Sickle Cell_____ Stomach _____ Vision
____ Other: ______
Please explain: ______
Psychological/Psychiatric History:
Current Diagnosis: ______
______
Examiner: ______Date: ______
Previous Diagnosis: ______
______
Examiner: ______Date: ______
Current Medication:
MedicationDosageFor
______
______
______
______
Other History: (Please note any other relevant information pertaining to the child and/or family.)
______
PLEASE NOTE:
For admission, Glenwood must have copies of the following applicable documents:
•Comprehensive Assessments
•Individual Service Plan (ISP)
•Individualized Education Plan (IEP)
•Immunization Record
•Physical Exam/ TB skin test (current)
•Birth Certificate
•Psychological and/or psychiatric evaluations
•EPDST
•Medicaid Card/Insurance Card (both sides)
•Social Security Card
•Court Orders
•Approval letter from state for funding (multi-needs referrals only)