Juvenile Justice Referral Questionnaire
Thank you for your interest in Hearts of Hope Care Homes programs and services. Our goal is to help all kids and families receive the highest quality of care. To ensure accurate and timely placement, please provide as much information as possible. However, feel free to skip any questions that you do not have answers for. If you have any questions about this form, an admissions representative is happy to help. Please contact them at 720-812-8307 or info@heartsofhopecarehome.org. Once you submit the form, we will be in contact within 48 business hours.
Client Name
*
First Name
Last Name
Client Date of Birth
*
-
Month
-
Day
Year
Date
Client Gender Identity
*
Female
Male
Transgender female
Transgender male
Nonbinary
other
Preferred Pronouns
*
She/her
He/him
They/them
What program are you referring for?
*
Residential Services
Community Services
Life Skills Coaching
Independent Living Program
Unsure
Bridge2Home Rapid Program
Family Support and Resource Pavilion (FSRP)
Other
Client Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Phone Number
Please enter a valid phone number.
Client Email
example@example.com
How did you hear about Hearts of Hope Care Homes
*
County Dept of Human Services
Hospital
HHCH Employee
School
Social Media
Community Outreach Manager
Court System
Other
Legal Guardian (if applicable)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Primary Language Spoken in the Home
Therapeutic privilege (LAN) holder (if applicable):
First Name
Last Name
Caseworker (if applicable):
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Does this client have an Individualized Education Plan (IEP)?
Yes
No
I dont know
Guardian Ad Litem (GAL) name (if applicable):
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Current School (if applicable)
Current Grade (if applicable)
4. Do you believe people (the age you listed above) is fully aware of their actions?
Not at all
Half the time
Absolutely
Primary Insurance Provider
Policy Number
Secondary Insurance Provider
Policy Number
Health Information
Mental Health Diagnoses (if applicable)
Medical Conditions (for example, asthma, allergies, diabetes, seizures, dietary needs, etc.)
Is the client currently on any medications?
*
Please Select
Yes
No
Unsure
Name of Meds, Dosage, Dosage Times & Dr Name
Has the client experienced any trauma (for example, abuse, neglect, removal from home, inconsistent caregivers, traumatic incidents, etc.):
Family Information
Please list the individuals currently residing in the client's home.
Cultural Considerations
Safety concerns for staff going into the home (for example aggression towards staff, gang involvement, aggressive pets, weapons, etc.)
Check the conditions that apply to the client.
*
Animal Cruelty
Anxiety
Cognitive Functioning
Depression
Developmental Delays
Elopement Running
Enuresis/Encopresis
Gang Involvement
Homicidal Ideation
Hygiene
Other
Physical Agression
Property Damage
Psychosis/Hallucinations
School Truancy
Self Harm
Setting Fires
Sexualized Behaviors
Substance / Alcohol Abuse
Suicidal Ideation
Verbal Agression
Please share any additional information about the conditions you listed including the frequency, intensity, and duration.
Please share with us more information regarding the client and/or family system including why services are needed, strengths and interests, and desired outcomes from hearts of hope care homes services.
Referral Source Information
This section asks for information about the person making this referral.
Contact Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Funder of Services
Referring Agency
Submit
Should be Empty: