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.

Youth under the age of 13 will not be eligible for detention

Name of Youth:*

Date of birth*

Date

Gender of youth:*

MaleFemaleOther

Address of Youth:*

School last attended by youth*

Current grade for youth; Last grade attended*

Date of last attendance at school:*

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

YesNo

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?*

YesNo

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?

YesNo

If no please list the youth's legal guardian

Parent/Legal Guardian Marital Status

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

E.T.A.*

County Agency Requesting Placement:*

Youth Status

Court WardAct 150Pending Act 150 Status

Date Act 150 status became effective

County Agency responsible for payment:*

Name of Probation Officer/Caseworker:*

Email address of PO/Caseworker*

example@example.com

Probation Officer/Caseworker #*

Please enter a valid phone number.

24 hour contact #*

Please enter a valid phone number.

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*

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?*

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 $170 not including medical expenses for youth referred by County and $185 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.*

Yes

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.*

Yes

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.*

Yes

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