MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION RESIDENTIAL TREATMENT REFERRAL	LEVEL:	SECTION A
Date of Referral:
Case Manager Name	CM’s Telephone #	Supervisor Name	Supervisor Signature	Supervisor’s Phone #
Child’s Identifying Information
Child’s Name (Last, First, Middle)	DCN	Age	Race	Gender	Identified Gender	Height	Weight
Parent/Guardian Name	Contact Number	Insurance Provider
Currently Suspended from School? Yes No	Grade	FSIQ:	List any Serious Medical Conditions:
Funding Source: CD Adoption Subsidy Legal Guardianship Subsidy DYS DMH FCCM
Other
Check any of the below services which have been previously used with this child in an effort to preserve his/her placement or avoid residential placement: FCS Intensive-In Home Services Out-Patient Counseling Psychiatric Services Kinship Care Traditional Foster Care - # of Placements: Level A Homes - # of Placements: Level B Homes - # of Placements: Medical Foster Home - # of Placements: DMH – Division of Developmental Disabilities (DD) Referral Date: DMH – Division of Behavioral Health (BH) Referral Date:	Check all service referrals made for the child and outcome: Elevated Needs A: Date: Outcome: Elevated Needs B: Date: Outcome: Medical Home Referral: Date: Outcome:
What is the post-placement plan for the youth? Parents/Guardian Relative/Kinship Provider Foster Home Elevated Needs Home Therapeutic Foster Home Transitional Living DD Comprehensive Waiver DD Host Home
Reason for Referral – Describe current behaviors (within the past 30 days) and provide specific examples, as well as triggers to behavior (if known). If the referral is to step a child down to a less restrictive residential setting, such as Therapeutic Foster Home or lower level of treatment, describe what has occurred in the last 30 days to indicate the child is ready for this transition.
Required Documentation (must be attached): Immunization Record Birth Certificate Current Court Order Social Summary
Discharge Summaries from Prior Residential Placement Current Prescriptions (if 30 days of medication(s) not available for provider) and Doctor’s Orders Current IEP/504 Plan Medical Records (if child has a current diagnosed medical condition) or letter from doctor documenting diagnosis and treatment needs Most recent Psychological Evaluation If no recent Psychological Evaluation, provide most recent Psychiatric Evaluation If no Psychological/Psychiatric Evaluations, provide recent therapist/counseling reports if child is receiving counseling
Other

CHILDHOOD SEVERITY OF PSYCHIATRIC ILLNESS (3.1)

(Complete for children/youth 6 years old or older)

RISK BEHAVIORS

Check	1. SUICIDE RISK Please rate the highest level from the past 30 days
0	No evidence.
1	History but no recent ideation or gesture.
2	Recent ideation or gesture but not in past 24 hours.
3	Current ideation and intent OR command hallucinations that involve self-harm.

Check	2. SELF-MUTILATION Please rate the highest level from the past 30 days
0	No evidence.
1	History of self-mutilation.
2	Engaged in self-mutilation that does not require medical attention.
3	Engaged in self-mutilation that requires medical attention.

Check	3. OTHER SELF HARM Please rate the highest level from the past 30 days
0	No evidence of behaviors other than suicide or self-mutilation that place the child at risk of physical harm.
1	History of behavior other than suicide or self-mutilation that places child at risk of physical harm. This includes reckless and risk-taking behavior that may endanger the child, including substance use.
2	Engaged in behavior other than suicide or self-mutilation that places the child in danger of physical harm. This can include reckless behavior or intentional risk-taking behavior or substance use.
3	Engaged in behavior other than suicide or self-mutilation that places the child at immediate risk of death. This can include reckless behavior or intentional risk-taking behavior or substance use.

Check	4. DANGER TO OTHERS Please rate the highest level from the past 30 days
0	No evidence.
1	History of homicidal ideation, physically harmful aggression, or fire setting that has put self or others in danger of harm.
2	Recent homicidal ideation, physically harmful aggression, or dangerous fire setting but not in past 24 hours.
3	Acute homicidal ideation with a plan or physically harmful aggression OR command hallucinations that involve the harm of others OR child set a fire that placed others at significant risk of harm.

Check	5. SEXUAL AGGRESSION Please rate the highest level from the past 30 days
0	No evidence of any history of sexually aggressive behavior. No sexual activity with younger children, non-consenting others, or children not able to understand consent.
1	History of sexually aggressive behavior, but child has not engaged in sexually aggressive behavior for the past year OR sexually inappropriate behavior in the past year that troubles others, such as harassing talk or excessive masturbation.
2	Child is engaged in sexually aggressive behavior in the past year but not in the past 24 hours.
3	Child has engaged in sexually aggressive behavior in the past 24 hours.

Check	6. RUNAWAY Please rate the highest level from the past 30 days
0	No evidence.
1	History of runaway from home or other settings involving at least one overnight absence, at least 30 days ago.
2	Recent runaway behavior or ideation but not in past 7 days.
3	Acute threat to runaway as manifested by either recent attempts OR significant ideation about running away OR child is currently a runaway.

Check	7. JUDGMENT Please rate the highest level from the past 30 days
0	No evidence of problems with judgment or poor decision making that result in harm to development and/or well-being.
1	History of problems with judgment in which the child makes decisions that are in some way harmful to his/her development and/or well-being. For example, a child who has a history of hanging out with other children who shoplift or use substances.
2	Problems with judgment in which the child makes decisions that are in some way harmful to his/her development and/or well-being.
3	Problems with judgment that place the child at risk of significant physical harm.

Check	8. FIRESETTING Please rate the highest level from the past 30 days
0	No evidence.
1	History of fire setting but not in the past six months.
2	Recent fire-setting behavior (in past six months) but behavior has not endangered the lives of others (e.g., playing with matches) OR repeated fire-setting behavior over a period of at least two years even if not in the past six months.
3	Acute threat of fire setting. Set fire that endangered the lives of others (e.g. attempting to burn down a house).

Check	9. SOCIAL BEHAVIOR Please rate the highest level from the past 30 days
0	No evidence of problematic social behavior.
1	Mild level of problematic social behavior. This might include occasional inappropriate social behavior. Comments to strangers or unusual behavior in social settings might be included in this level.
2	Moderate level of problematic social behavior. For example, frequent cursing in public would be rated here.
3	Severe level of problematic social behavior. Child’s social behavior places him/her at risk for serious sanctions (e.g., suspension, expulsion from school, loss of foster home). For example, threatening others would be rated here.

BEHAVIORAL/EMOTIONAL SYMPTOMS

Check	10. PSYCHOSIS Please rate the highest level from the past 30 days
0	No evidence.
1	History or suspicion of hallucinations, delusions or bizarre behavior that might be associated with some form of psychotic disorder.
2	Clear evidence of hallucinations, delusions, or bizarre behavior that might be associated with some form of psychotic disorder.
3	Clear evidence of dangerous hallucinations, delusions, or bizarre behavior that might be associated with some form of psychotic disorder which places the child or others at risk of physical harm.

Check	11. IMPULSE/HYPERACTIVITY Please rate the highest level from the past 30 days
0	No evidence.
1	Some problems with impulsive, distractible or hyperactive behavior that places the child at risk of future functioning difficulties.
2	Clear evidence of problems with impulsive, distractible, or hyperactive behavior that interferes with the child’s ability to function in at least one domain.
3	Clear evidence of a dangerous level of impulsive behavior that can place the child at risk of physical harm.

Check	12. DEPRESSION Please rate the highest level from the past 30 days
0	No evidence.
1	History or suspicion of depression or mild to moderate depression associated with a recent negative life event with minimal impact on life domain functioning.
2	Clear evidence of depression associated with either depressed mood or significant irritability. Depression has interfered significantly in child’s ability to function in at least one life domain. Child may use illicit drugs or overuse prescription drugs to self-medicate. This may include significant withdrawal, avoidance, or elective mutism.
3	Clear evidence of a disabling level of depression that makes it virtually impossible for the child to function in any life domain.

Check	13. ANXIETY Please rate the highest level from the past 30 days
0	No evidence.
1	History or suspicion of anxiety problems or mild to moderate anxiety associated with a recent negative life event.
2	Clear evidence of anxiety associated with either anxious mood or significant fearfulness. Anxiety has interfered significantly in child’s ability to function in at least one life domain.
3	Clear evidence of debilitating level of anxiety that makes it virtually impossible for the child to function in any life domain.

Check	14. OPPOSITIONAL Please rate the highest level from the past 30 days
0	No evidence.
1	History or recent onset (past six weeks) of defiance towards authority figures.
2	Clear evidence of oppositional and/or defiant behavior towards authority figures, which is currently interfering with the child’s functioning in at least one life domain. Behavior causes emotional harm to others.
3	Clear evidence of a dangerous level of oppositional behavior involving harm or threat of physical harm to others.

Check	15. CONDUCT Please rate the highest level from the past 30 days
0	No evidence.
1	History or suspicion of problems associated with antisocial behavior including but not limited to lying, stealing, manipulating others, sexual aggression, violence towards people, property or animals.
2	Clear evidence of antisocial behavior including but not limited to lying, stealing, manipulating others, sexual aggression, violence towards people, property, or animals.
3	Evidence of a severe level of conduct problems as described above that places the child or community at significant risk of physical harm due to these behaviors.

Check	16. ADJUSTMENT TO TRAUMA Please rate the highest level from the past 30 days
0	No evidence.
1	History or suspicion of problems associated with traumatic life events.
2	Clear evidence of adjustment problems associated with traumatic life event(s). Adjustment is interfering with child’s functioning in at least one life domain.
3	Clear evidence of symptoms of Post Traumatic Stress Disorder, which may include flashbacks, nightmares, significant anxiety, and intrusive thoughts of trauma experience.

Check	17. ANGER CONTROL Please rate the highest level from the past 30 days
0	No evidence of any significant anger control problems.
1	Some problems with controlling anger. Child may sometimes become verbally aggressive when frustrated. Peers and family may be aware of and may attempt to avoid stimulating angry outbursts.
2	Moderate anger control problems. Child’s temper has gotten him/her in significant trouble with peers, family and/or school. Anger may be associated with physical violence. Others are likely quite aware of anger potential.
3	Severe anger control problems. Child’s temper is likely associated with frequent fighting that is often physical. Others likely fear him/her.

Check	18. SUBSTANCE USE Please rate the highest level from the past 30 days
0	No evidence.
1	History or suspicion of substance use. Child manifests problems and risk factors that appear to be related to substance use but do not meet diagnostic criteria for Substance Related Disorder as defined in DSM-IV-R. Includes suspicion of using illicit drugs to self- medicate mental health or other conditions. Tobacco use only would be rated here. [Substance use]
2	Clear evidence of substance abuse that interferes with functioning in any life domain. Using illicit drugs to self medicate could be rated here. [Substance abuse]
3	Child requires detoxification OR is addicted to alcohol and/or drugs. Include here a child/youth who is intoxicated at the time of the assessment (i.e., currently under the influence). [Dependence (history known)]

FUNCTIONING PROBLEMS

Check	19. LIVING SITUATION Please rate the highest level from the past 30 days
0	No evidence of problem with functioning in home-like settings.
1	Mild problems with functioning at home. Caregivers concerned about child’s behavior at home.
2	Moderate to severe problems with functioning at home. Child has difficulties maintaining his/her behavior in this setting creating significant problems for others in the home.
3	Profound problems with functioning at home. Child is at immediate risk of being removed from home due to his/her behaviors.

Check	20. COMMUNITY Please rate the highest level from the past 30 days
0	No evidence of problems with functioning in the community.
1	Mild problems with functioning in the community. Child’s behavior has raised the concerns of some community members and/or institutions.
2	Moderate to severe problems with functioning in the community. Child has difficulties maintaining his/her behavior to avoid sanctions from community members and/or institutions.
3	Profound problems with functioning in the community. Child is at immediate risk of being removed from the community.

Check	21. SCHOOL Please rate the highest level from the past 30 days
0	Child is performing well in school.
1	Child is performing adequately in school although some problems may exist or child is enrolled in a special program.
2	Child is experiencing moderate problems with school attendance, behavior, and/or achievement. Recent declines in school performance or recent increases in school behavior problems would be rated here.
3	Child is experiencing severe problems in school with school attendance, behavior, and/or achievement. Recent suspensions or expulsions, non-attendance, or failing a grade would be rated here.

Check	22. PEER FUNCTIONING Please rate the highest level from the past 30 days
0	Child has healthy peer relationships.
1	Child is having some minor problems with his/her peers.
2	Child is having some moderate problems with his/her peers. This may include a limited number of peers or difficulties maintaining same age friendships.
3	Child is experiencing severe disruptions in his/her peers. This may include having very little social contact with peers or primary affiliation with a negative peer group (e.g., gang member).

Check	23. DEVELOPMENTAL Please rate the highest level from the past 30 days
0	Child has no developmental problems.
1	Child has some problems with physical immaturity or there are concerns about possible developmental delay. Child may have low IQ.
2	Child has developmental delays or mild mental retardation.
3	Child has severe and pervasive developmental delays or profound mental retardation.

Check	24. MEDICATION COMPLIANCE Please rate the highest level from the past 30 days
0	Child takes prescribed medications as prescribed and without problems or child is not currently on any prescribed medication.
1	Child will take prescribed medications routinely, but sometimes needs reminders to maintain compliance. Also, a history of medication noncompliance but no current problems would be rated here.
2	Child is somewhat non-compliant. The child may be resistant to taking prescribed medications or may tend to overuse his or her medications. He/she might comply with prescription plans for periods of time (1-2 weeks), but generally does not sustain taking medication in prescribed dose or schedule.
3	Child and/or caregivers are not compliant with prescribed medications or child abuses prescription medication.

JUVENILE JUSTICE

Check	25. JUVENILE JUSTICE STATUS Please rate the highest level from the past 30 days
0	No current involvement with the court system.
1	Status offense: juvenile/family conflict, in-county runaway, truancy, petty offenses OR immediate risk of involvement with the court system.
2	Moderate juvenile delinquency: offenses against persons, offenses against property, drug related offenses or underage drinking.
3	Felony criminal activity: serious offenses against persons or property (e.g., robbery, aggravated assault, possession with intent to distribute controlled substances, 1st or 2nd degree offenses).

Check	26. COMMUNITY SAFETY Please rate the highest level from the past 30 days
0	No evidence of any risk to the community from the child’s behavior.
1	Child has a history of presenting a significant physical risk to community members or a mild to moderate risk of other negative outcomes.
2	Child’s current behavior represents a moderate risk of physical danger or a significant risk of other negative outcomes.
3	Child’s current behavior represents a significant risk of physical danger to members of the community.

Check	27. DELINQUENCY Please rate the highest level from the past 30 days
0	No evidence.
1	History of delinquency but no acts of delinquency in past 30 days.
2	Recent acts of delinquency, including drug-related acts or underage drinking.
3	Severe acts of delinquency that place others at risk of significant loss or injury or place child at risk of adult sanctions. Includes driving while under the influence of drugs and/or alcohol.

CHILD PROTECTION

Check	28. ABUSE OR NEGLECT (Note: Current Caregivers only are rated here.) Please rate the highest level from the past 30 days
0	No evidence the child is at risk for physical or sexual abuse with current caregivers.
1	Child has a history of abuse with current caregivers but he/she is not currently at risk.
2	Child is at risk of abuse or neglect; CD Protective Services must be contacted.
3	Child at immediate risk of abuse or neglect and requires immediate protection.

*All referents are legally required to report suspected child abuse or neglect to CD.

Check	29. DOMESTIC VIOLENCE Please rate the highest level from the past 30 days
0	No evidence of domestic violence between caregivers in family or household.
1	Child has a history of exposure to domestic violence but no current violence in the household.
2	Child is exposed to domestic violence in the household. CD Protective Services must be called.
3	Child is in danger due to domestic violence in the household. Child requires immediate protection.

CAREGIVER NEEDS & STRENGTHS

Check	30. HEALTH/BEHAVIORAL HEALTH Please rate the highest level from the past 30 days
0	Caregiver is generally healthy.
1	Caregiver is in recovery from medical, physical, mental health or substance use problems or has mild or controlled health problems that have the potential to complicate parenting.
2	Caregiver has medical, physical, mental health or substance use problems that interfere with their parenting role.
3	Caregiver has medical, physical, mental health or substance use problems that make it impossible for them to parent at this time.

Check	31. SUPERVISION Please rate the highest level from the past 30 days
0	Caregiver has good monitoring and discipline skills.
1	Caregiver provides generally adequate supervision. May require occasional help or technical assistance.
2	Caregiver reports difficulties monitoring and/or disciplining child. Caregiver requires assistance to improve supervision skills.
3	Caregiver is absent or requires considerable help to monitor or discipline the child. Caregiver requires immediate and continuing assistance. Child at risk of harm to self due to absence of supervision.

Check	32. INVOLVEMENT Please rate the highest level from the past 30 days
0	Caregiver is able to act as an effective advocate for child.
1	Caregiver has history of seeking help for his/her children. Caregiver is open to receiving support, education, and information.
2	Caregiver does not wish to participate in services and/or interventions intended to assist his/her child.
3	Caregiver wishes for child to be removed from his/her care.

Check	33. SOCIAL RESOURCES Please rate the highest level from the past 30 days
0	Caregiver has significant family, friends or a social network that actively helps family and child.
1	Caregiver has some family, friends, or a social network that actively helps with family and child.
2	Caregiver has some family, friends, or a social network that may be able to help with family and child
3	Caregiver has no family, friends, or social network that may be able to help with family and child.

Check	34. RESIDENTIAL STABILITY Please rate the highest level from the past 30 days
0	Caregiver has stable housing for the foreseeable future.
1	Caregiver has relatively stable housing but either has moved in the past three months or there are indications of housing problems that might force them to move in the next three months.
2	Caregiver has moved multiple times in the past year. Housing is unstable.
3	Caregiver has experienced periods of homelessness in the past six months.

MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION	DATE	SECTION B
RESIDENTAL TREATMENT REFERRAL MATERNITY AND PARENTING CARE	CHILD’S NAME
DUE DATE	DOCTOR’S NAME	LAST DOCTOR’S VISIT
DOCTOR’S TELEPHONE	DOCTOR’S ADDRESS
WHERE IS SHE CURRENTLY PLACED	CURRENT LEVEL OF PLACEMENT
WHY
CURRENT MEDICATIONS
PAST MEDICATIONS
IS THIS THE FIRST PREGNANCY?	YES	NO	AT WHAT AGE WAS THE FIRST PREGNANCY?
CHILDREN
NAME	GENDER	DATE OF BIRTH	PLACEMENT
NAME	GENDER	DATE OF BIRTH	PLACEMENT
NAME	GENDER	DATE OF BIRTH	PLACEMENT
SEXUAL ISSUES (CHECK ALL THAT APPLY. EXPLAIN ALL ITEMS THAT ARE CHECKED).
RAPE	INCEST
SEXUAL ABUSE	SEXUALLY ACTIVE
PREGNANCY ISSUES (CHECK ALL THAT APPLY. SUMMARIZE ALL ITEMS THAT ARE CHECKED).
PLANNED PREGNANCY	ACCIDENTAL PREGNANCY
PLANS TO PARENT THE CHILD	PLANS TO RELINQUISH BABY FOR ADOPTION
UNDECIDED ABOUT PARENTING THE CHILD	PREVIOUS RELINQUISHMENTS
TERMINATED PREVIOUS PREGNANCY	PREVIOUS MISCARRIAGES
HIGH RISK FACTORS PRESENT	COMPLICATIONS IN CURRENT PREGNANCY
USED DRUGS BEFORE PREGNANCY	USED DRUGS DURING PREGNANCY
COMPLICATIONS IN PREVIOUS PREGNANCY	OTHER:
EXPLAIN
ATTITUDE TOWARD PREGNANCY?
ATTITUDE TOWARD PARENTING?
WHAT BEHAVIOR CHANGES HAS MOTHER EXHIBITED SINCE BECOMING PREGNANT?

CHILD’S NAME
WHAT IS MOTHER’S SUPPORT SYSTEM?
WHAT FAMILY INVOLVEMENT IS EXPECTED IN THE PREGNANCY AND AFTER CARE FOR MOTHER AND BABY?
WHO MODELED PARENTING FOR MOTHER?
HOW DOES MOTHER SEE THE BABY CHANGING HER LIFE?
WHAT IS MOTHER’S RELATIONSHIP TO BABY’S FATHER?
FATHER’S INFORMATION
BABY’S FATHER’S NAME	DATE OF BIRTH	FATHER’S DCN
FATHER’S TELEPHONE NUMBER	FATHER’S ADDRESS
FATHER’S ATTITUDE TOWARD PREGNANCY/PARENTING
ANY RESTRICTIONS ON CONTACT?
DOES THE FATHER HAVE A HISTORY OF CHEMICAL ABUSE?
COMMENTS

MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION	DATE	SECTION C
RESIDENTAL TREATMENT REFERRAL INFANT AND TODDLER CARE	CHILD’S NAME
FOR ALL CHILDREN AGE BIRTH THROUGH SIX MONTHS
BABY’S WEIGHT AT BIRTH	BABY’S LENGTH AT BIRTH	GESTATIONAL AGE
FOR ALL CHILDREN AGE BIRTH THROUGH SIX YEARS RISK FACTORS; (CHECK ALL THAT APPLY AND SUMMARIZE ALL THAT ARE CHECKED)
MOTHER HAS HISTORY OF DRUG USE DURING PREGNANCY	TOILET TRAINING PROBLEMS
MOTHER HAS HISTORY OF ALCOHOL USE DURING PREGNANCY	ENURETIC
MOTHER HAS HISTORY OF SUBSTANCE ABUSE	ENCOPRETIC
FATHER HAS HISTORY OF SUBSTANCE ABUSE	HISTORY OF SLEEP PROBLEMS
CHILD TESTED POSITIVE FOR DRUGS AT BIRTH	HISTORY OF NIGHTMARES
CHILD HAD WITHDRAWAL SYMPTOMS AT BIRTH	HISTORY OF NIGHT TERRORS
INCONSISTENT PRENATAL CARE	SERIOUS SEXUAL ABUSE
NO PRENATAL CARE	SERIOUS PHYSICAL ABUSE
LOW APGAR SCORE	HISTORY OF SERIOUS PHYSICAL TRAUMA
LOW BIRTH WEIGHT	CHILD IS SELF-ABUSIVE
IRRITABLE	CHILD LACKS JUDGMENT REGARDING PERSONAL SAFETY ISSUES
OVERSTIMULATED	CHILD ON MEDICATION
DIFFICULT TO CONSOLE	CHILD ON NEBULIZER
CHILD DIAGNOSED WITH A FETAL ALCOHOL SPECTRUM DISORDER, INCLUDING FETAL ALCOHOL SYNDROME	CHILD ON VENTILATOR
CHILD TESTED HIV POSITIVE	CHILD ON APNEA MONITOR
CHILD HAS AIDS	MORE THAN TWO MEDICAL APPOINTMENTS PER MONTH
MOM TESTED HIV POSITIVE	CHILD REQUIRES SPECIAL EQUIPMENT
SEIZURE HISTORY	PLAY THERAPY NEEDED
ASTHMA HISTORY	PHYSICAL THERAPY NEEDED
CARDIAC DEFECT	OCCUPATIONAL THERAPY NEEDED
VISUAL OR HEARING IMPAIRMENT	SPEECH THERAPY NEEDED
HIGH LEAD LEVELS	HISTORY OF MULTIPLE CAREGIVERS
DEVELOPMENTALLY DELAYED	NO ATTACHMENT TO ANY ADULT
HISTORY OF FEEDING PROBLEMS	DEMONSTRATES LIMITED INVOLVEMENT WITH CARETAKERS
COLIC	CHILD CLINGS
FAILURE TO THRIVE	CHILD ATTACHES INDISCRIMINATELY
OTHER
COMMENTS

DEVELOPMENTAL ASSESSMENT (CHECK ALL THAT APPLY AND SUMMARIZE ALL THAT ARE CHECKED)
AGE APPROPRIATE	SLIGHT DELAY	MODERATE DELAY	SEVERE DELAY	NOT APPLICABLE
LANGUAGE SKILLS
GIVES APPROPRIATE RESPONSE TO QUESTIONS
RESPONDS TO DIRECTIONS
FINE MOTOR SKILLS
GROSS MOTOR SKILLS
USES STAIRS
COORDINATED
UNSTEADY
PERCEIVES THE ENVIRONMENT
RESPONDS TO THE ENVIRONMENT
APPEARS CURIOUS
BASIC PROBLEM-SOLVING SKILLS
PROGRESSIVE EFFORTS TO PROBLEM SOLVE
RECOGNIZES COMMON OBJECTS
ENGAGES IN PLAY
ENGAGES IN ACTIVITIES
PLAYS WELL WITH OTHERS
TOILET TRAINED
COMMENTS
ATTACHMENT ISSUES
DESCRIBE THE EVIDENCE OF BONDING
DESCRIBE THE MOTHER/CHILD RELATIONSHIP

MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION	DATE	SECTION D
RESIDENTAL TREATMENT REFERRAL FAMILY – FOCUSED RESIDENTIAL CARE	CHILD’S NAME
BARRIERS TO FAMILY REUNIFICATION (CHECK ALL THAT APPLY – SUMMARIZE ALLTHAT ARE CHECKED)
FAMILY	CHILD
SAFETY ISSUES:	SAFETY ISSUES:
PARENTAL HISTORY OF SUBSTANCE ABUSE	ENVIRONMENTAL RISKS IN NEIGHBORHOOD
PARENTAL HISTORY OF PHYSICAL ABUSE	CHILD REFUSES TO ATTEND SCHOOL
PARENTAL HISTORY OF SEXUAL ABUSE	EDUCATIONAL NEEDS
PARENTAL HISTORY OF EMOTIONAL ABUSE	COURT-ORDERED PLACEMENT ISSUES
PARENTING POTENTIAL:	CHILD’S IDENTIFIED PROBLEMS
UNSKILLED	AGGRESSIVE BEHAVIOR
PHYSICAL IMPEDIMENTS	CONDUCT ISSUES
MENTAL HEALTH ISSUES
PHYSICAL LIMITATIONS:
HOUSING
TRANSPORTATION
ACCESS TO RESOURCES
MOTIVATION:	MOTIVATION:
PARENTAL HISTORY OF COOPERATION WITH CD	CHILD DOES NOT WANT TO REUNIFY
PARENT HAS SOUGHT HELP SINCE REMOVAL	CHILD HAS SOUGHT HELP FOR PROBLEMS
PARENT WANTS THE CHILD RETURNED
SUPPORT SYSTEM:	SUPPORT SYSTEM
FAMILY	FAMILY
FRIENDS	FRIENDS
CHURCH	CHURCH
THERAPIST	THERAPIST
OTHER (EXPLAIN)	OTHER (EXPLAIN)
COMMENTS

MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN’S DIVISION	DATE	SECTION E
RESIDENTAL TREATMENT REFERRAL TRANSITIONAL LIVING PROGRAM (TLP)	CHILD’S NAME
CHECK THE YOUTH’S POTENTIAL FOR TLP PROGRAMMING
POOR	AVERAGE	OUTSTANDING	NOT APPLICABLE
ACADEMIC ACHIEVEMENT
EMPLOYMENT HISTORY
MOTIVATION FOR EMPLOYMENT
MOTIVATION FOR TLP SUCCESS
SELF-IMAGE
RESPONSE TO STRESS
KNOWLEDGE OF LIFE SKILLS
MATURITY LEVEL
FAMILY / OTHER SIGNIFICANT SUPPORT
INTERPERSONAL RELATIONSHIPS
COMMENTS
BRIEFLY SUMMARIZE THE YOUTH’S IMMEDIATE TLP GOALS
DOES THE YOUTH NEED MEDICATION? YES NO	IF YES, WHAT IS THE MEDICATION / DOSAGE?
DOES THE YOUTH CURRENTLY SELF-ADMINISTER THE MEDICATION? YES NO	DOES THE DOCTOR APPROVE THE YOUTH TO SELF-MEDICATE? YES NO
DOES THE YOUTH HAVE A VALID DRIVER’S LICENSE? YES NO	IF YES, DOES THE YOUTH HAVE AUTOMOBILE INSURANCE? YES NO
IF YES, WHAT IS THE INSURANCE COMPANY NAME, ADDRESS, AND TELEPHONE NUMBER?

ATTACH A BRIEF SUMMARY OF THE YOUTH’S UNDERSTANDING OF THE TLP PROGRAM
ATTACH A BRIEF RECOMMENDATION FROM THE CASE MANAGER
DATE COMPLETED LIFE SKILLS PROGRAM	CD YES NO	OTHER (EXPLAIN)
ATTACH A BRIEF RECOMMENDATION FROM THE APPROPRIATE INDEPENDENT LIVING PROGRAM (ILP) STAFF
COMMENTS