Charlevoix County Probate / Family Court
S H A R P Referral Packet
Safe Harbor Adolescent Recovery Program
INSTRUCTIONS FOR COMPLETING S H A R P REFERRAL FORM:
1)Fill out the form COMPLETELY. The areas included on this 5-page document were streamlined to make it easier to refer a youth. It is difficult to process the youth with incomplete information.
2)Please feel free to use additional space if needed.
3)DO NOT SKIP THE FAMILY MEMBER information section. It is important to understand whether the youth lives with their family members or not, if they have siblings, bio-mother, bio-father (or other).
4)If you have any questions you may contact the director, John McLean at 231-547-8192, or 231-675-3803 at any time. Please leave a message or even text him – he will get back to you. You may also email him at:
5)RETURN the form via email to if you do not have email access you may FAX the form to 231-547-1323 but be sure and call John McLean to confirm it did arrive. (We work in a fast paced environment with archaic technology at times). Be sure and attach or send along any Substance Abuse evaluation or findings, Psychological Evaluations or Counselor/Therapists opinions that will help indicate the youth’s level of addiction, problems and other information that will assist us
6)Once you have received confirmation that your referral has been accepted, you can submit the INTAKE PACKET. Please read the instructions for completing that as well. As with any government entity it is becoming a necessity to submit the proper information PRIOR to the youth’s arrival.
7) If it is indicated that the youth is under the care and custody of someone other than his biological/adoptive parents – the referring court MUST provide a copy of the Letters of Guardianship issued by the appropriate court giving legal authority to the adult who is signing the INTAKE PACKET documents. If this is a family court situation, the Order indicating the youth was placed in the care and custody of someone other than his/her parent MUST be included with the paperwork.
8) BIRTH CERTIFICATE, IMMUNIZATION RECORD, COURT ORDER AND SCHOOL INFORMATION IS NOW A REQUIREMENT.
Safe Harbor Adolescent Recovery Program (SHARP)
Intake Information
Referral date: ______
Youth
Name of youth: ______Date of Birth:______
Age: _____ Gender:______Social Sec Number: ______
Height:______Weight: ______Eye Color: ______Hair Color: ______
Address:______
City: ______State: ______Zip: ______
Phone: (_____) ______-______Cell: (____) _____ - ______Work: (___) ___ - ____
Religious Preference: ______
Referring Agency:
Agency Name: ______County: ______
Address: ______
City: ______State: ______Zip: ______
Phone Number: (______) ______- ______Fax Number: (______)______- ______
Probation Officer/Caseworker: ______
Email: ______
Cell Phone Number: (_____)_____-______Direct Contact Officer Number: (_____)_____-______
Emergency/Afterhours contact: ______
(please provide a name and number rather than “911”)
Prior TREATMENT Placements:
LocationDate AdmittedDate Discharged
1./ / / / _
2./ / / / _
3./ / / / _
4./ / / / _
Behavior History:
YES,NO YESNO
Aggressive behavior___________Unlawful drive-away______
Verbally assaultive___________Obsessions______ Details:
Sexually assaultive___________Suicidal ideations______
Teen mother/father?___________Gang involvement______
Safety Concerns:
YES NOYESNO
Eating disorders___________History of runaway______
Self-harm (i.e. Cutting)___________Setting fires______
Suicide attempts___________
Alcohol / Drug Use History
Drug Age of 1st use Date of last use Frequency / Duration O.D.?
1.______
2.______
3.______
4.______
5.______
Number of days clean: ______Does client need detox?Yes______No______
: “Drug of Choice”
Please note any prior assessments:Ethnicity: (Check all that apply)
Psychological Yes___No___Pending______American Indian___Pacific
AcademicYes___No___Pending______Alaskan Native___Asian
Substance abuseYes___No___Pending______Black ___White
___Hispanic___Latino
Other: ______
Education History
School (current enrollment): ______Grade:______
Address ______
City:______State ______Zip______
Phone(______) _____-______Fax: (______) ______-______
Does the client have a current or past history of Special Education Services (IEP or 504)?
IF YES, PLEASE PROVIDE US WITH A COPY OF THE CLIENT’S MOST RECENT EVALUATION.
Personal Interests / Hobbies (include list of hobbies and interests and changes if noted):
Employment History
EmployerLengthPositionOutcome
1.______
2.______
3.______
4.______
Parental Information
Bio/adopted-Mother______Bio/adopted-Father ______
D.O.B. ______D.O.B.______
Address ______Address______
City ______State______City______State______
Zip______Zip______
Phone (______) ______-______Phone (______) ______-______
Step-Mother ______Step-Father ______
D.O.B. ______D.O.B.______
Address ______Address______
City ______State______City______State______
Zip ______Zip______
Phone (______) ______-______Phone (______) ______-______
Family History
- include names & ages of immediate and extended family members
- indicate which members are in the household of residence
- note history of mental illness, major medical problems, and/or alcohol/drug abuse and/or concerns
Family memberRelationAgeinMedical MentalDrugAlcohol
houseProblemsillnessabuseabuse
1.______Bio-Dad______
2.______Bio-Mom______
3.______Step-Dad______
4.______Step-Mom______
Family History (cont.)
Family memberRelationAgeinMedicalMentalDrugAlcohol
houseProblemsillnessabuseabuse
5.______
6.______
7.______
8.______
Describe why youth is being referred to SHARP (attach any supporting documentation)
______
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