UNIVERSE KONADU Recommendation Form
Please Note: All recommendations require that an Introductory Interview be completed in order to determine the youth/family/individual's eligibility, need and level of care. Questions? Feel free to contact our offices at (800) 979-1495 and one of our team members will be delighted to assist you. Thank you for your interest in our programs and services!
Date/Time of Recommendation Submission
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Month
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Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Recommending Agency
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Service Start Date Request
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Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Service End Date Request
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Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Name of Person Making Recommendation
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First Name
Last Name
Contact Number of Person Making Recommendation
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Part I - Recommendation Information
Name of person being recommended. If recommending parent-child or family please use the information of the primary individual receiving services. You will have the opportunity to enter the remaining information in the designated field at the bottom of this form.
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First Name
Last Name
Please indicate type of service(s) requested:
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Confidential Family Assessment
Group/One to One Mentoring (Youth)
Parent-Child
Parent Only
Individual
Family
Please indicate total number of units/hours requested per program/service month:
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Date of Birth & Age
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Cyber ID#
Medicaid Number
Gender
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Racial/Ethnic Background
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Language
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Religious Affiliation(s)
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Hobbies & Interests
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Any pets in the home? Please list them here.
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Parent Name
First Name
Last Name
Parent Name
First Name
Last Name
Email
example@example.com
Email
example@example.com
Best Contact Number
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Best Contact Number
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Does anyone in the home smoke? If so, who?
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If recommending more than one person (i.e. parent-child or family), please use this section to provide detailed background information on the additional individuals being recommended.
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What is your desired outcome for the person(s) as a result of being part of the program and/or service?
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Please provide additional information about the program and/or service you are requesting. This will assist us with making the best recommendation.
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Part II - Youth History
Does the youth have a history of running away? If yes, please explain.
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Does the youth have a history of self-harm? If yes, please explain.
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Does the youth have a history of violence? If yes, please explain.
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Does the youth have a history of low academic functioning? If yes, please explain.
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Has the youth ever been detained? If yes, please explain.
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How did the youth/family become involved with JJC/DCPP, etc? Please explain.
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Who does the youth currently reside with? If not with parent(s), why?
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What is the youth’s diagnosis?
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Is the youth currently on medication? If so, what?
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Is there parent-child conflict present in the home? If yes, please explain.
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Is there additional information we need to be aware of?
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Signature
Worker/Authorized Agent Signature
Supervisor Signature
Continue
Continue
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