My Place Referral Form

Please fill out your contact information as the referring agency.

Please enter your First and Last Name: Please enter your First and Last Name: First Last
Please enter your Email:
Referring Agency:
What role do you currently occupy at your agency?
Phone: Phone: - ### - ### ####
Date: Date: / MM / DD YYYY
Please enter the Client's First and Last Name: Please enter the Client's First and Last Name: First Last
Please Enter the Client's Race:

Please Enter the Client's Race: Alaskan Native American Indian and Alaskan Native Asian Black/African American Native Hawaiian or Other Pacific Islander Black/African American White Other single race Two or more races
Please enter the Client's Ethnicity (Optional):

Please enter the Client's Ethnicity (Optional): Dominican Hispanic or Latino Not Hispanic or Latino
Please enter the Client's Date of Birth: Please enter the Client's Date of Birth: / MM / DD YYYY
How does the client identify?

How does the client identify? Male Female Transgender Female-to-Male/FTM/Transgender Male Male-to-Female/MTF/Transgender Female Genderqueer, neither exclusively male or female Other Other
Describe the circumstances that resulted in the client coming into foster care
Discuss the client's placement history
Adjudication Type:

Adjudication Type: Abuse Neglect Delinquency Other Other
Has the youth ever been named as the perpetrator of sexual abuse or a sexually related offense?

Has the youth ever been named as the perpetrator of sexual abuse or a sexually related offense? Yes No
Please explain
Has the youth ever been a victim of sexual abuse?

Has the youth ever been a victim of sexual abuse? Yes No
Is the client pregnant, parenting, or expecting to parent while residing at My Place?

Is the client pregnant, parenting, or expecting to parent while residing at My Place? Yes No
Do they have custody of their child?

Do they have custody of their child? Yes No
Does the youth have any health concerns?

Does the youth have any health concerns? Yes No
Please describe the youth's health concerns
Does this youth have a mental health diagnosis

Does this youth have a mental health diagnosis Yes No
Please describe the client's mental health diagnosis
Please include the name of the person who completed the most recent mental health assessment Please include the name of the person who completed the most recent mental health assessment First Last
Please include the date of the most recent mental health assessment Please include the date of the most recent mental health assessment / MM / DD YYYY
Does the client use drugs or alcohol?

Does the client use drugs or alcohol? Yes No
Please select the following drugs used by the youth

Please select the following drugs used by the youth Marijuana Central Nervous System Depresants (Benzos) Cocaine (Coke/Crack) GHB Hallucinogens Heroin Inhalants Ketamine Khat Kratom LSD (Acid) MDMA (Ecstacy/Molly) Mescaline (Peytoe) Methamphetamine (Crystal/Meth) Over-the-Counter Medicines - Dextromethorphan (DXM) Over-the-Counter Medicines - Loperamide PCP (Angel Dust) Prescription Opiods (Oxy/Percs) Prescription Stimulants (Speed) Psilocybin (Magic Mushrooms/Shrooms) Rohypnol (Flunitrazepam/Roofies) Salvia Steroids (Anabolic) Syntehtic Cannabinoids (K2/Spice) Synthetic Cathinones (Bath Salts/Flakka) Tobacco/Nicotine and Vaping Other Other
Please explain the frequency of each drug use
Does the youth have a history of explosive behavior?

Does the youth have a history of explosive behavior? Yes No
Please outline the youth's triggers for explosive behavior
Is the client linked with services?

Is the client linked with services? Yes No
Please explain the services the client is linked with
Please outline the Extended Service Team (Include: Probation, counselors, caseworkers, attorney's, GAL's, etc):