Application for Intensive In-Home Services Eliada Homes, Inc. "*" indicates required fields Student InfoStudent Name*Preferred Name*Date of Birth*Age*Race*SSN*Gender*Preferred PronounsCurrent Living Arrangement*Legal CustodianCustodian Name*Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent Legal Guardian is Parent Parent NamePhoneEmail Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code NotesCase Responsible AgencyCase Responsible Agency*Case Responsible Professional*Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Who is making referral?*NameContact Number*Contact numberRelationship to client*Relationship to clientSchool PlacementSchool Name*Phone*IEP?*YesNo504?*YesNoHistory of truancy/suspensions or expulsions?*YesNoFunding SourceFunding Source Name*Insurance/Medicaid Number*MCO Record Number*MCOMCO Name*Care Coordinator*Phone*Email* Primary Care PhysicianPhysician Name*Practice*PsychiatristPsychiatrist Name*Practice*Placement/Hospitalization History None Level of CareAdmission DateDischarge DateReason for PlacementDJJ Court Counselor None Counselor NamePhoneEmail Current StatusCurrent behaviors/presenting problems and reason for referral*Primary DiagnosesPrimary Diagnoses*Date*By Whom?*Additional DiagnosesAdditional DiagnosesDateBy WhomAdditional DiagnosesDateBy WhomAdditional DiagnosesDateBy WhomMedicationsMedicationDoseFrequencyMedicationDoseFrequencyMedicationDoseFrequencyMedicationDoseFrequencyMedicationDoseFrequencyIs the student compliant with medications?Current StressorsLegal Problems*YesNoDescribePhysical Assault*YesNoDescribeAddiction*YesNoDescribeMedical Problems*YesNoDescribeRelationship Problems*YesNoDescribeAbuse History*YesNoDescribeSexual Assault/Rape*YesNoDescribeSeparation/Loss*YesNoDescribeSelf-Injurious/Suicidal Behaviors*YesNoDescribeSubstance Use History*YesNoDescribeSexualized Behaviors*YesNoDescribePsychotic Behaviors*YesNoDescribeOther*YesNoDescribeConsent* Family has been notified and agrees to the referralNameThis field is for validation purposes and should be left unchanged.
