Selah House Level 3 Group Home Referral Placement Form
Date of Referral
-
Month
-
Day
Year
Date
Referring Agency/Individual
Contact Person
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Client Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Age
Gender
Please Select
Female
Male
Legal Guardian (if applicable)
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Placement Reason
Check all that apply
Unsafe/Hazardous Behaviors
Aggressive/Defiant Behaviors
Legal/Juvenile Justice Involvement
Problematic Sexual Behaviors
Other
If other please specify
Presenting Concern
Briefly describe the behaviors or circumstances leading to this referral
Current Diagnoses (if applicable)
Primary Diagnosis
Secondary Diagnosis
Medications (if any)
Other
Behavioral History
History of Substance Use
History of Violence/Aggression
AWOL/Runaway Risk
Self-Harm/Suicidal Ideation
Involvement with Juvenile Justice/DSS
Current Living Situation
Current Service Providers
Reason for Transition
Additional Information (Any other relevant details that should be considered for placement)
Requested Services at Selah House
Residential Behavioral Health Treatment
Trauma-Informed Care & Therapy
Substance Use Counseling
Anger Management Program
Vocational Training & Educational Support
Other
Approval & Submission
Referring Party Signature
Date
-
Month
-
Day
Year
Date
Supporting Documents Attached
Yes
No
Please submit the completed form to BC4Y, contact@bc4y.org. For any questions, contact BC4Y at 704-870-9584.
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