Selah House Level 3 Group Home Referral Placement Form

Selah House Level 3 Group Home Referral Placement Form
Date of Referral

MonthDayYear
Date
Referring Agency/Individual
Contact Person

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Client Information
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Gender
Legal Guardian (if applicable)

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Placement Reason
Check all that apply

Unsafe/Hazardous BehaviorsAggressive/Defiant BehaviorsLegal/Juvenile Justice InvolvementProblematic Sexual BehaviorsOther
If other please specify
Presenting Concern
Briefly describe the behaviors or circumstances leading to this referral
Current Diagnoses (if applicable)

Primary DiagnosisSecondary DiagnosisMedications (if any)Other
Behavioral History

History of Substance UseHistory of Violence/AggressionAWOL/Runaway RiskSelf-Harm/Suicidal IdeationInvolvement 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 TreatmentTrauma-Informed Care & TherapySubstance Use CounselingAnger Management ProgramVocational Training & Educational SupportOther
Approval & Submission
Referring Party Signature

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Date

MonthDayYear
Date
Supporting Documents Attached

YesNo
Please submit the completed form to BC4Y, contact@bc4y.org. For any questions, contact BC4Y at 704-870-9584.
Should be Empty:

Selah House Level 3 Group Home Referral Placement Form

Client Information

Placement Reason

Presenting Concern

Approval & Submission