The Open Door House Referral Application
Use this form to refer someone to The Open Door House program. Complete all requested referral, history, medical, and signature details.
Referral Information
Referral Source (organization / person)
*
Referral Source Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager
Case Manager Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Case Manager Email
example@example.com
Reason for referral
*
Current living situation
*
Former foster youth
Yes
No
How long in foster care
Income Source
Employed
Extended Foster Care
Social Security
Other
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Involvement History
Fire Setting
*
Yes
No
Fire Setting Date
-
Month
-
Day
Year
Date
Fire Setting Notes
Violent/Assault with Weapons
*
Yes
No
Violent/Assault with Weapons Date
-
Month
-
Day
Year
Date
Violent/Assault with Weapons Notes
Property Destruction
*
Yes
No
Property Destruction Date
-
Month
-
Day
Year
Date
Property Destruction Notes
Gang Affiliation
*
Yes
No
Gang Affiliation Date
-
Month
-
Day
Year
Date
Gang Affiliation Notes
Sexual Offense
*
Yes
No
Sexual Offense Date
-
Month
-
Day
Year
Date
Sexual Offense Notes
Charges Pending Felony/Misdemeanor
*
Yes
No
Charges Pending Felony/Misdemeanor Date
-
Month
-
Day
Year
Date
Charges Pending Felony/Misdemeanor Notes
Substance Use
*
Yes
No
Substance Use Date
-
Month
-
Day
Year
Date
Substance Use Notes
Suicide Thoughts
*
Yes
No
Suicide Thoughts Date
-
Month
-
Day
Year
Date
Suicide Thoughts Notes
Suicide Attempts
*
Yes
No
Suicide Attempts Date
-
Month
-
Day
Year
Date
Suicide Attempts Notes
Baker Act (i.e., Involuntary Commitment)
*
Yes
No
Baker Act / Involuntary Commitment Date
-
Month
-
Day
Year
Date
Baker Act / Involuntary Commitment Notes
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Medical and Treatment Information
Case Manager / Therapist Name
*
Is there a current diagnosis?
*
Axis I
Axis II
Axis III
Axis IV
Diagnosis Axis V (GAF)
Current Medication - Name
Current Medication - Dosage
Current Medication - Reason
Past Medication - Name
Past Medication - Dosage
Past Medication - Reason
Medical Conditions / Allergies
List Any Medical Conditions / Allergies
Current Therapist
Current Therapist Phone #
Please enter a valid phone number.
Format: (000) 000-0000.
Agency Name
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Person Completing Form
*
Person Completing Form Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Signature of Person Completing Form
*
Date Signed
*
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: