R13 Program Inquiry Form

Reclaim13 Program Inquiry Form

Please complete this form to be contacted about a Reclaim13 program.
Please allow up to two business days for your inquiry to be processed. In most cases, determinations will be made within 4 business days.

If this is an emergency and you need immediate assistance please contact your nearest emergency room or call 911.

Please visit here for more information regarding suicide prevention & support.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Are you completing this form to refer yourself or someone else?
Reclaim13 Programs

RESIDENTIAL PROGRAMS: Therapeutic living environment. Therapy, psychiatry, case management, & mentoring are a part of these programs.

COMMUNITY PROGRAMS: Individual receives services in the community but resides in his/her own home.

If you are interested in referring yourself or someone else for therapy, please email THERAPY@RECLAIM13.ORG to connect you directly to the therapy team.
To which program would you like to referral the individual or yourself?
Is this a request for an emergency placement?

Other
Where is the referred client currently staying?
How long can the referred client remain at their current location?
Referral Source Information

Please enter the information for the caller/source that is referring a potential client.
Referral/Agency Contact

First NameLast Name
Name of Agency or Referral Source

Other
Name of Agency or Referral Source
Ex. Referring agency name, self, guardian
Referral Source Phone
Format: (000) 000-0000.
Referral Source Email (or your email if referring self)
example@example.com
Referred Client Information

Please enter the below details for the client referred to a Reclaim13 program.
Name of Individual

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearSelect from calendar to auto-calculate age
Age
In years
What gender were you assigned at birth?
How do you identify?
Guardian Information

Complete if the client referred is a minor
What is your relation to the individual being referred?

Other
Parent/Legal guardian name

First NameLast Name
Location of referred Individual

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of referred Individual or Parent/Legal guardian
Format: (000) 000-0000.
Department of Children & Family Services (DCFS)
Is the referred individual in custody of the Department of Children and Family Services (DCFS)?
Caseworker Information
Caseworker Name

First NameLast Name
Caseworker Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Caseworker Phone Number
Format: (000) 000-0000.
Caseworker Email
example@example.com
Clinical Documentation

If you do not have clinical documentation you will be redirected to a new link to complete additional information.
Does this youth have clinical documentation from previous placements?
Please Note:

If you do not have clinical documentation, then you will be redirected to a new link to complete additional information once you submit this form.
Please upload clinical documents for this is a youth in care (DCFS) referral for Cherish House for review. (Integrated Assessment, current placement discharge information, etc.)

Browse Files

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Additional Information
Please give a brief description of the reason for services
How did you hear about us?

Other
Any additional comments or notes? (Optional)
If this is an emergency, or the referred individual is in crisis, please contact 911 or go to your nearest emergency room.

Please visit here for more information regarding suicide prevention.
Should be Empty:

Reclaim13 Program Inquiry Form

Referral Source Information

Referred Client Information

Guardian Information

Department of Children & Family Services (DCFS)

Caseworker Information

Clinical Documentation

Additional Information