INTAKE REQUEST FORM

Once you select submit at the end of this form it will be sent to the Bay County Juvenile Home email. Please follow up with a phone call if you are not contacted. This email is not constantly monitored. 989-892-4519. We try to respond to all requests. Please check your spam/junk folders, especially with state of Michigan emails. Per diem is $180 for Court youth and $195 for DHHS youth.

Age of youth (Youth under the age of 13 will not be eligible for detention)

Name of Youth:

Date of birth

Date

Gender of youth:

Other

Address of Youth:

School last attended by youth

Last Grade Attended

Date of Last School Attendance

Date

Has this youth been in detention or residential placement in the past?

If yes please list placements.

Has this youth shown a propensity for violence in previous placements or programs?

1 Name of Parent/Guardian:

1 Phone#:

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

1 Parent Guardian email address to send permission forms

Is this parent the youth's legal guardian?

If no please list the youth's legal guardian:

2nd Parent/Guardian:

2nd Parent/Guardian Phone #

2nd Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

2nd Parent/Guardian email address

Is this the youth's legal guardian?

If no please list the youth's legal guardian

Parent/Legal Guardian Marital Status

When was the youth's last dental exam?

Is the youth up to date on immunizations?

When was the youth's last wellness exam?

Medical insurance information for the youth

Parent/Guardian/Grandparent allowed access to youth (please list names and numbers if not above)

Parent/Guardian/Grandparent NOT allowed access to youth (please list names)

Date/Day Needed for Placement:

Date

Estimated time of arrival

County Agency Requesting Placement:

If are completing for someone else please enter name, number and email address:

Date Act 150 status became effective

Youth Status

County or Agency responsible for payment:

Example: List County and Court or If court is not responsible note County name and DHHS

Name of Probation Officer/Caseworker:

Email address of PO/Caseworker

example@example.com

Probation Officer/Caseworker #

Please enter a valid phone number.Format: (000) 000-0000.

24 hour contact #

Please enter a valid phone number.Format: (000) 000-0000.

Current Charges/Offense(must include original charges if violation of probation or court order) Youth with a status offense or violation of probation/court order on a status offense will not be accepted:

Does this youth have adult charges or being waived over to adult court?

Per Licensing Rule 400.4152 (h) Please provide a brief description of the circumstances leading to the need for placement

Estimated Length of Stay

Lengths of stay are limited to 30 days. Special circumstances may be discussed with Director.

Any known medical problems or disabilities including learning disabilities; Please note if youth is pregnant:

Is the youth in need of medical or mental health attention? This refers to prior to the youth entering the facility. Services at this facility are limited as this is a short term detention. Is there a plan for needed mental health or medical services?

Has there been recent drug or alcohol use by the youth (48hours)?

What type of use? PBT or other test results?

Prescribed Medications (Bring with resident at time of intake):

If on medication will there be enough for the youth's stay? Refills? Doctor of prescribing medications?:

Inhaler/glasses etc...

Comments or additional information:

I am aware that the per diem rate is $190 not including medical expenses for youth referred by County and $215 for youth under MDHHS supervision. This cost will be billed monthly to the agency responsible for payment as listed on this form. The County will be billed medical/medication expenses monthly.

The court will provide a copy of the MJJAS/OYAS DET Screening tool and Score sheet utilized to indicate that the youth is high risk and appropriate for detention .

I understand that youth may not arrive to the facility wearing electronic monitoring devices of any kind. These devices must be removed prior to being detained.

I understand to review the information packet on the Bay County Juvenile Home website and sign off on the acknowledgment form listed below the packet. A packet will be sent to the referring agency by request. I will encourage the legal guardian of the youth to review this information and sign off on the acknowledgment and sign the consent forms for medical, immunization and dental. Dental and immunization may be denied in writing.

I understand there must be an order signed by the authorizing authority of the court that can order the youth to be detained in the Bay County Juvenile Home detention facility indicating anticipated length of time youth will be detained. The order shall also allow consent for routine, nonsurgical medical care or emergency medical and surgical treatment of the youth while detained. This is required to be in the youth's case file at the time of admission per CCI licensing rule 400.4152 (f)(g) as provided in 1973 PA 116 MCL 722.124a 14a (1), (2) and (3). REQUIRED

The referring court and court officers (or DHHS JJ Worker) understands that the youth may be requested to be removed for any reason. The BCJH anticipates to allow at least 24 hours for removal if the youth is not a danger to self or others. Otherwise the removal may be requested immediately. NO EXCEPTIONS YOU MUST HAVE A 24 HOUR EXIT PLAN

I understand the youth will be quarantined for 1 days (24 hours) upon arrival. The youths symptoms will be monitored and a minimum of 1 rapid COVID-19 test will be provided prior to release to the general population. COVID-19 screen the day of arrival and temperature taken. Youth may be quarantined in accordance to recommendations from the CDC.

After selecting submit, this form will be directed to the Bay County Juvenile Home email. Please follow through with a phone call as this email is not constantly monitored. Please be able to provide a court order that allows for routine medical and dental consent. We will contact the parent/guardian for consent signatures. You may direct the parent/guardian to our website to complete forms.

BAY COUNTY JUVENILE HOME RESIDENT INTAKE REQUEST FORM