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ANOTHER LEVEL YOUTH AND FAMILY SERVICES, LLC
1
Date Of Referral:
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Date
Month
Day
Year
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2
Referred By:
Referral Name
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3
Agency
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4
Client Name:
First Name
Middle Name
Last Name
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5
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
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Belarus
Belgium
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Benin
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Bolivia
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Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
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Cape Verde
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Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
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Cook Islands
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Denmark
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The Gambia
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Gibraltar
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Guam
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Guinea-Bissau
Guyana
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Hong Kong
Hungary
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India
Indonesia
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Iraq
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Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
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Kosovo
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Laos
Latvia
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Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
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Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
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Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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6
Phone Number:
Area Code
Phone Number
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7
Social Security Number:
Social Security
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8
Date Of Birth
-
Date Of Birth
Month
Day
Year
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9
Age:
Age:
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10
Gender:
Male
Female
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11
Ethnicity:
Race
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12
Parent/Legal Guardian:
Parent/Lar
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13
Parent Phone Number:
Area Code
Phone Number
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14
Relationship To Client:
Relationship
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15
Medicaid Number:
Medicaid Number
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16
PCP Name:
PCP
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17
School Attending:
School
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18
Grade:
Grade
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19
Special Education Services?
Yes
No
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20
If Yes:
IEP
504
Other
IEP
504
Other
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21
If You Selected Other Please Detail Here:
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22
Reason For Referral/Presenting Problems
(include behavioral, psychiatric and medical problems,current medications, and history of medical care)
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23
Individual's Current Living Situation:
Residential
Group Home
Foster Care
Independent Living Prog.
Biological Family
Community
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24
If you Selected Community List Here:
Community
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25
Does This Individual Currently Receive Case Management?
Yes
No
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26
If Yes, provide the Name and Contact Number Of The Case Management Services Provider:
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27
Name:
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28
Agency:
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29
Phone Number:
Area Code
Phone Number
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30
Medical:
Significant Medical Problems
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31
Currently On Medications?
Yes
No
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32
If Yes, List your Medications Here:
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33
Date Of Last Physical Exam:
-
Date
Month
Day
Year
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34
History of Services Received:
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35
**Must be within the last 30-90 days**
At-risk of out of home placement (detention, fostercare, jail, kinship, etc.) as a result of behaviors in the home,school, and community that have become more disabling over time. (See attached behavior checklist)
The individual demonstrates such inappropriatebehaviors that repeated interventions by mental health, social services, or judicial systemare or have been necessary, resulting in risk of out of home placement.(Refer to above sections: History of Services Received and Current Services, does not include the VICAP)
The individual exhibits difficulty in cognitiveability such that they are unable to recognize personal Danger orrecognize significantly inappropriate social behavior to such a degree thatthey are at risk of out ofhome placement. (ex. Does indv.know right from wrong, do the act out although they know what they are doing is wrong ordespite knowing there will be consequences to themselves or others, do theycontinue to act out despite potential injury to self orothers, etc.)
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36
IIH Behavior/Concern Checklist
Yes
No
Unk.
Access To Weapons
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Cruelty To Animals
Row 1, Column 0
Row 1, Column 1
Row 1, Column 2
Violence Toward Others
Row 2, Column 0
Row 2, Column 1
Row 2, Column 2
Self-Harm
Row 3, Column 0
Row 3, Column 1
Row 3, Column 2
Legal Involvement
Row 4, Column 0
Row 4, Column 1
Row 4, Column 2
Destruction Of Property
Row 5, Column 0
Row 5, Column 1
Row 5, Column 2
Fire Setting
Row 6, Column 0
Row 6, Column 1
Row 6, Column 2
Hallucinations
Row 7, Column 0
Row 7, Column 1
Row 7, Column 2
Homelessness
Row 8, Column 0
Row 8, Column 1
Row 8, Column 2
Homicidal Ideas
Row 9, Column 0
Row 9, Column 1
Row 9, Column 2
Depression
Row 10, Column 0
Row 10, Column 1
Row 10, Column 2
Suicidal Ideation
Row 11, Column 0
Row 11, Column 1
Row 11, Column 2
Extreme Violence
Row 12, Column 0
Row 12, Column 1
Row 12, Column 2
Substance Use/Abuse
Row 13, Column 0
Row 13, Column 1
Row 13, Column 2
Medication Non-Compliance
Row 14, Column 0
Row 14, Column 1
Row 14, Column 2
Gang Involvement
Row 15, Column 0
Row 15, Column 1
Row 15, Column 2
Bed Wetting/Soiling
Row 16, Column 0
Row 16, Column 1
Row 16, Column 2
Stealing
Row 17, Column 0
Row 17, Column 1
Row 17, Column 2
Sexually Assualting
Row 18, Column 0
Row 18, Column 1
Row 18, Column 2
Poor Self-Care
Row 19, Column 0
Row 19, Column 1
Row 19, Column 2
Noncompliance
Row 20, Column 0
Row 20, Column 1
Row 20, Column 2
Access To Weapons
Cruelty To Animals
Violence Toward Others
Self-Harm
Legal Involvement
Destruction Of Property
Fire Setting
Hallucinations
Homelessness
Homicidal Ideas
Depression
Suicidal Ideation
Extreme Violence
Substance Use/Abuse
Medication Non-Compliance
Gang Involvement
Bed Wetting/Soiling
Stealing
Sexually Assualting
Poor Self-Care
Noncompliance
Yes
Row 0, Column 0
No
Row 0, Column 1
Unk.
Row 0, Column 2
Yes
Row 1, Column 0
No
Row 1, Column 1
Unk.
Row 1, Column 2
Yes
Row 2, Column 0
No
Row 2, Column 1
Unk.
Row 2, Column 2
Yes
Row 3, Column 0
No
Row 3, Column 1
Unk.
Row 3, Column 2
Yes
Row 4, Column 0
No
Row 4, Column 1
Unk.
Row 4, Column 2
Yes
Row 5, Column 0
No
Row 5, Column 1
Unk.
Row 5, Column 2
Yes
Row 6, Column 0
No
Row 6, Column 1
Unk.
Row 6, Column 2
Yes
Row 7, Column 0
No
Row 7, Column 1
Unk.
Row 7, Column 2
Yes
Row 8, Column 0
No
Row 8, Column 1
Unk.
Row 8, Column 2
Yes
Row 9, Column 0
No
Row 9, Column 1
Unk.
Row 9, Column 2
Yes
Row 10, Column 0
No
Row 10, Column 1
Unk.
Row 10, Column 2
Yes
Row 11, Column 0
No
Row 11, Column 1
Unk.
Row 11, Column 2
Yes
Row 12, Column 0
No
Row 12, Column 1
Unk.
Row 12, Column 2
Yes
Row 13, Column 0
No
Row 13, Column 1
Unk.
Row 13, Column 2
Yes
Row 14, Column 0
No
Row 14, Column 1
Unk.
Row 14, Column 2
Yes
Row 15, Column 0
No
Row 15, Column 1
Unk.
Row 15, Column 2
Yes
Row 16, Column 0
No
Row 16, Column 1
Unk.
Row 16, Column 2
Yes
Row 17, Column 0
No
Row 17, Column 1
Unk.
Row 17, Column 2
Yes
Row 18, Column 0
No
Row 18, Column 1
Unk.
Row 18, Column 2
Yes
Row 19, Column 0
No
Row 19, Column 1
Unk.
Row 19, Column 2
Yes
Row 20, Column 0
No
Row 20, Column 1
Unk.
Row 20, Column 2
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37
Detail Any Other Criteria Here:
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38
If You Answered "Yes" To Any Of The Above, Please Provide A Brief Description Including How Often The Behavior Occurs- Discuss Intensity (how bad; to what degree); Duration (how long do the incidents last); and Frequency (how often do the behaviors occurs):
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