Consumer Name *

First Name

Last Name

Consumer DOB *

MM

DD

YYYY

Consumer Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian / Caregiver Name *

First Name

Last Name

Guardian Phone *

(###)

###

####

Other Phone *

(###)

###

####

Is the consumer in active therapy or psychiatry? *

If "yes", please provide their contact information below.

Yes

No

Clinician's Name *

First Name

Last Name

Clinician's Phone Number *

(###)

###

####

Who is completing this form? *

Case Manager

Social Worker

Therapist

Other

Please provide your name *

First Name

Last Name

Referral Source Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Referral Source Phone *

(###)

###

####

Referral Source Fax *

(###)

###

####

Which of the following conditions have been met by the youth? (Check all that apply, must check a min. of 1) *

Youth is at risk for emergency psychiatric hospitalization as one possible treatment option, though not necessarily the only treatment option or has had at least one emergency psychiatric hospitalization within the past 12-24 months

Youth is placed in or being considered for placement in a group home facility or above or is in a monitored treatment facility for the treatment of mental health needs

Class membership criteria as listed above has not been established but maximum 30 calendar day unplanned contact is requested due to urgent or emergency conditions that jeopardize child/youth current living arrangement

Youth is transitioning to a lower level of care and needs TBS to support the transition

Youth may need out of home placement, a higher level of residential or acute care

Youth has previously received TBS from another organization

Consumer demonstrates impairment as a result of the included diagnosis (at least one of the following applies): *

Significant impairment in an important area of life functioning {e.g., living situation, daily activities, or social support}

A reasonable probability of significant deterioration in an important area of life functioning

A reasonable probability a person under 21 years of age will not progress developmentally as individually appropriate

History of Physical/Sexual/Emotional/Domestic Violence Abuse: *

Sexual Abuse

Physical Abuse

Emotional Abuse

Domestic Violence

Substance Abuse

Alcohol Abuse

N/A

Is the consumer involved in any legal matters? *

If 'Yes" please provide their contact info below.

Yes

No

Point of Contact *

First Name

Last Name

Phone *

(###)

###

####

Fax *

(###)

###

####

Signature *

First Name

Last Name