SHELTER CARE REQUEST FORM

During regular business hours (Monday – Friday: 8 a.m. – 5 p.m.)

Please complete the following questions. Fax all information to the Attn. of Wendy Borman-Burman, Director of Programs/Admissions, at: 701-255-6261. Call Donalda at 701-391-4045 to alert her to your incoming fax and to discuss specifics related to your referral. If you wish to email this form, please omit the youth’s name to maintain confidentiality and contact Wendy by telephone to provide fax-omitted information. Email: .

A decision will be made based on availability of beds/residential placement, appropriateness of placement for RCCF level of care, and anticipated impact on other youth currently residing in the group home.

After hours and on weekends

Youthworks (Bismarck) should be phoned at 701-255-7229, until the next business day. Then follow the above directions to make your referral.

Referral Information

Date of referral:

Name of referred youth:

Date of Birth:

Person/Agency requesting placement:

Custodian authorizing placement:

Who authorizes payment?

Family contact person if other than custodian:

Anticipated placement date:

Diagnosis:

Axis I:

Axis II:

Axis III:

Axis IV

Axis V (GAF):

Additional Referral Information

1. Please describe the extent of any current or prior substance use.

2. Has the youth been under the influence of drugs or alcohol in the past 24 hours? Y N

If yes, describe level of impact/sobriety and any substance abuse issues.

3. Is or has the child recently been hospitalized for depression or suicide? Y N

If yes, please describe.

4. Describe any current/recent psychotic or suicidal behavior or any self injury (e.g., cutting,

burning, binge/purging).

5. Does the youth exhibit aggressive behaviors toward self and/or others? Y N

If yes, please identify individuals targeted (e.g., mom, dad, peers, siblings).

6. Describe the youth’s current legal situation, citations or adjudications.

7. Is there a known history of sexually acting out, placing the youth or others at risk? Y N

If yes, please describe.

8. Shelter care youth placed with Charles Hall Youth Services must be able to attend public

school. What grade level/school program will the youth attend if placed at Charles Hall?

Is the youth on an IEP?

9. Does the youth have any medical conditions or concerns which require daily maintenance

(e.g., asthma, diabetes)?

10. Does the youth take medication(s) Y N? Please list all medications, including OTC, and

why are they needed?

11. Has the child in the last 12 months had a psychological evaluation? Y N

If so, when and by whom/agency

12. Has the child in the last 12 months had an addiction evaluation? Y N

If so, when and by whom/agency

13. Briefly describe why the youth cannot return home and what efforts have been made to

resolve family/placement conflict issues via less restrictive efforts.

14. What would be the discharge plan for the youth?

15. What services have been provided or will be provided to the youth’s family while the youth is

in care at Charles Hall?

FOR CHYS use only:

Name of staff reviewing Referral: ______

Outcome: ______

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Shelter Care Referral Form

1.21.2014