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Service needed
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In-home Crisis Respite
Traditional foster care
Crisis respite (CADI/DD)
Independent Living Skills (ILS)
Person completing referral
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Agency/County
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Phone number
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Email
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Name of individual to be served
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What does the individual like to be called?
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Individual's DOB
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Race
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other pacific Islander
White
Declined to answer
Child protection involvment
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Yes
No
Gender Indentity
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Female
Male
Non-Binary
Transgender
Pronouns
Religion
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Does the individual have a social security number?
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Yes
No
Yes, but I do not have access to it
Most recent CSSP (coordinated services support plan)
Most Recent Diagnostic assessment
Social & medical information
Insurance type
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PMI number
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Preferred emergency hospital
Current Diagnoses
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+
-
Allergies
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-
Complicating behaviors (If none please enter N/A)
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History (Please include Relevent family history, Medical conditions, Reason for placement)
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Current medication list, if no meds please put N/A (Please include ALL prescribed Medications)
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+
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Upcoming appointments
Education
School Name
School Contact
In-person/Virtual
In-person Learning
Virtual learning
Care Team information
Legal Guardian (Name, email & number)
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Case Manager (Name, email & number)
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Waiver Manager (Name, email & number)
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Emergency Contact (Name, Email & number)
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If referral is being sent by email please use contact information below:
*** Usually responds within 3 business days
Darnesha Whitfield
Referrals@thriveyouthservices.org
(763)-777-5604
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