The Lampstand Safehome Intake Form
Thank you for completing this next step of the referral process to The Lampstand safehome! If you have any questions, please contact us at 540-777-4663 or TLSreferrals@thelampstandva.org
Your Information
Name of Person Submitting this Form
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First Name
Last Name
Your Phone Number
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Your Email
*
Please describe your relationship with the Survivor on behalf of whom you are completing this form:
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Survivor's Demographic Information
Please fill out the following information about the Survivor who is being referred to The Lampstand safehome.
Survivor's Name
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First Name
Last Name
Date of Birth
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Month
-
Day
Year
Date
Social Security Number
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Citizenship
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Race
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Height
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Weight
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Hair Color
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Eye Color
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Emergency Contact Information
Other than Custodian
Is the Survivor in Department of Social Services Case Management? Is "yes", please provide the name and contact information of the Survivor's DSS Case Manager below:
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Yes
No
Name
Phone Number
Relationship to the Survivor
Family Contact Information
Father's Name
*
Father's Phone Number
*
Father's Email Address
Mother's Name
*
Mother's Phone Number
*
Mother's Email Address
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Medical and Dental Information
Please provide the name of the Survivor's Medical Doctor and the facility where they practice
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Please provide the Survivor's insurance type
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Medicaid
Private
No Insurance
Health Insurance Company
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Member ID
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Group Number
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RxBin
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RcPCN
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RcGRP
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Policy Holder's Name
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Policy Holder's Date of Birth
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Please attach a copy of the Survivor's health insurance card.
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Please provide the name of the Survivor's Dentist and the facility where they practice
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Please provide the date of the Survivor's last dental exam
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Month
-
Day
Year
Date
To your knowledge, does the Survivor need medical help at this time?
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Yes
No
If "yes", please explain:
Please list all medication (prescription and over the counter) the Survivor is currently taking and the reason for the medication.
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Does the Survivor have any known allergies?
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Yes
No
If "yes", please list allergies:
Behavioral Health Information
Does the Survivor have any mental health diagnoses?
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Yes
No
If "yes", please list all diagnoses:
Has the Survivor ever been treated by a Behavioral Health Clinician?
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Yes
No
If "yes", please describe what the Survivor was treated for, the name of the Clinician who treated the Survivor, and the dates the Survivor was treated.
Has the Survivor suffered any loss or separation in the past 12 months?
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Yes
No
If "yes", please explain:
Please check all behaviors exhibited by the Survivor (current or past)
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Lying
Steals
Fighting
Has leadership ability
Bullying
Considerate of others
Sudden mood changes
Runaway behavior
Abusive to self
Disrespect of authority
Profanity
Depressed
Anxiety attacks
Suicidal thoughts and/or gestures
Poor hygiene
Walks in sleep
Does not sleep well
Has nightmares
Shows off
Complains others don't like her
Sucks thumb
Very jealous
Self-confident
Enuresis (wets bed/clothes)
Encopresis (soils bed/clothes)
Suspicious
Nervous
Very lethargic
Abusive to animals
Abusive to smaller children
Has been sexually abused
Sexually abusive to others
Sexually active
Speech disorder
Vision impairment
Hearing impairment
Easily discouraged
Tobacco use
Alcohol use
Marijuana use
Other illicit drug use
Inhalants
Has strong hates
Has unusual dears
Does not eat well
Follows directions well
Overly dependent for age
Generally happy
Holds grudges
Overactive
Controls temper
Creative
Daydreams a lot
Affectionate
Withdrawn
Low self-esteem
Very shy
Very stubborn
Disobedient
Has a short attention span
Sociable
Promiscuous
School work refusal
Truancy
Anorexic (eating disorder)
Bulimic (eating disorder)
Other
Please check all the Survivor has experienced:
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Terrorism
Teen Dating Victimization
Death of immediate family member or caregiver
Adoption
Foster Care
Hate Crimes
Homelessness
Immigrant / Refugee / Asylum Seeker
Gang violence
Kidnapping (custodial)
Kidnapping (non-custodial)
Mass Violence
Stalking/Harassment
Domestic/Family Violence
Neglect
Pornography
Physical Abuse
Sexual Abuse
Robbery
Burglary
Arson
Vehicular Victim (i.e. hit and run)
Other
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Religion
Does the Survivor subscribe to a particular religion?
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Yes
No
If "yes", please provide the religion and the way in which the Survivor practices the religion.
Has religion ever been used as a tool of manipulation or control to the Survivor?
*
Yes
No
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Education
Name of the school the Survivor is currently attending
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What is the Survivor's current grade placement?
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What grades, if any, has the Survivor repeated?
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Has the Survivor received any ESL (English as a Second Language) services?
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Yes
No
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Additional Survivor & Family Information
What recent events or behaviors lead you to inquire about placement within The Lampstand residential program at this time?
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Please describe the Survivor's strengths
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Please describe the strengths of the Survivor's family
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Briefly state your goals for the Survivor
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Briefly state your goals for the family
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Please explain why you think this Survivor would benefit from placement at The Lampstand
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How did you hear about The Lampstand?
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SUBMIT
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