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Multi Systemic Therapy (MST)

Service Referral & Application

I. YOUTH INFORMATION

NAME: / SCHOOL: / GRADE:
ADDRESS: / SPECIAL NEEDS STUDENT: YES NO
PHONE:
( ) - ext ___ / SCHOOL CONTACT:
DATE OF BIRTH: / AGE: / MR Number:
RACE/ETHNICITY: / MALE
FEMALE / MEDICAID Number:

II. REFERRAL INFORMATION

REFERRAL SOURCE / PHONE NUMBER / AGENCY

III. FAMILY HISTORY

Mother’s Name / Father’s Name
Address / Address
Phone Number / (H) / (C) / Phone Number / (H) / (C)
ALIVE / DECEASED / ALIVE / DECEASED
MARITAL STATUS –  SINGLE  MARRIED  DIVORCED / MARITAL STATUS –  SINGLE  MARRIED  DIVORCED
EXTENDED FAMILY / NAME / AGE / RELATIONSHIP TO YOUTH
LEGAL GUARDIAN
(if different from biological parents)
OTHERS LIVING IN THE HOME
Youth’s current placement / Home / Other family member / Program placement / Detention
Hospitalized / Other / Please Explain:
IV. HISTORY OF PLACEMENTS & SERVICES
Please list previous programs as well as other servicesthat youth/family has been involved with to address current problem.
PROGRAM / REFERRAL DATE / ADMISSION DATE / DISCHARGE DATE / SUCCESSFUL ?
 Yes  No
OUTCOME:
PROGRAM / REFERRAL DATE / ADMISSION DATE / DISCHARGE DATE / SUCCESSFUL ?
 Yes  No
OUTCOME:
PROGRAM / REFERRAL DATE / ADMISSION DATE / DISCHARGE DATE / SUCCESSFUL ?
 Yes  No
OUTCOME:

V. HISTORY OF PRESENTING PROBLEMS

Please check all that apply
Academic Failure
Assault/Aggressive Behavior
Excessive Dependence on Parents
Feelings of Anxiety
Fire Setting
Gang Associate (please elaborate)
Gang Involvement (please elaborate)
Negative Peer Associations / Physical/mental abuse
Poor Social Skills
Prostitution
Runaways
School Behavior Problems
Self-Mutilation
Sexual Abuse
Sexual Offense / Stealing
Substance Use
Suicide Attempts
Suicide Threat(s)
Temper Tantrums
Truancy
Withdrawn, Depression
Additional Presenting Problems/Comments:
VI.STRENGTHS AND WEAKNESSES
FAMILY STRENGTHS
FAMILY WEAKNESSES
YOUTH STRENGTHS
YOUTH WEAKNESSES

VII. SCHOOL PERFORMANCE

A. Is youth currently enrolled in school?  Yes  No C. Is youth frequently truant?  Yes  No

B. Has youth been retained?  Yes  No D. Number of times suspended from school: ______

VIII. MEDICAL HISTORY

A. Is the youth currently on medication?  Yes  No. If “YES”, please specify. ______

B. Known psychiatric diagnoses,medical issues, physical limitations, or allergies. ______

______

IX. DELINQUENT/UNDISCIPLINED BEHAVIOR

OFFENSE / DATE / ADJUDICATED / PROBATION
 Yes  No /  Yes  No
 Yes  No /  Yes  No
 Yes  No /  Yes  No
 Yes  No /  Yes  No
 Yes  No /  Yes  No
Has youth ever been placed in secure custody? / No. of times placed in secure custody
Please indicate additional restrictive measures imposed by DJJDP -

Has the youth’s parent/legal guardian been informed of this referral?  Yes  No

If yes, please complete attached Authorization for Disclosure and the Reciprocal Exchange of Information form.

What is the goal of proposed placement in this service/program?

Person completing referral / Agency/Title

Best time to contact you regarding referral: AMPM

Best Method: Email Phone Number

Disposition of referral (agency use)
Date Received:
Date of Contact:
Outcome:

Haven House Services,600 W. Cabarrus Street, Raleigh, NC27603

Phone: (919) 833.3312Fax: (919) 833.3512

600 W. Cabarrus Street, RaleighNC27603

(919) 833.3312 (office) - 833.3512 (fax)

Authorization for Disclosure and the Reciprocal Exchange of Information

I, , parent/legal guardian of , hereby authorize the above-named facility to obtain and release following protected health information regarding my child from/to:

Name/Agency:

Address:

Phone:

Parent/Guardian to initial each category that applies. Enter n/a if not requested.

Psychological Evaluation Insurance Information

Alcohol/Drug Treatment Discharge Summary

Psychiatric Evaluation Admission Assessment/Social History

Medication History Treatment Plan & Diagnosis

Progress Notes Other:

The purpose of this disclosure is for: the coordination of treatment and care.

Once information is disclosed pursuant to this signed authorization, I understand the federal privacy (law 45 C.F.R. Part 164) protecting health information may not apply to the recipient of the information and therefore may not prohibit the recipient from disclosing it. Other laws, however, may prohibit re-disclosure. When we disclose mental health and developmental disabilities information protected by state law (G.S. 122C) or substance abuse treatment information protected by federal law (42 C.F.R. Part 2), we must inform the recipient of the information that re-disclosure is prohibited except as permitted or requested by these two laws. Our Notice of Privacy Practices describes where disclosure is permitted or required by the laws.

I understand that I may revoke this authorization at any time unless this authorization is given as condition of obtaining insurance coverage and the insurer has a legal right to contest the policy or claim under the policy. I understand that any revocation of this authorization must be submitted in writing and submitted to the Privacy Officer or their designees. In any event if not revoked, this authorization automatically expires one year from signature date.

I understand that I may refuse this authorization form. I understand that Haven House Services will not condition the client’s treatment or services on receiving my signature on this authorization. I certify that this authorization is made freely, voluntarily and without coercion. I understand health insurance indicated by my initials will be disclosed.

Client Name – please printClient Signature & Date

Parent/Legal Guardian – please printParent/Legal Guardian Signature & Date

Staff/Witness Name – please printStaff/Witness Signature & Date

Referral for Service & ApplicationMST REFERRAL UPDATED 12/10/12