Your Email (required)
Client's Name (required)
Client's ID# (required) LME Partners
Referring Staff and Agency
Client's Clinical Home Client's current services
Legal Guardian's Name Phone Number
Client's current diagnoses (including DD) PTSD, Sexual Abuse
Client's current prescribed medication
Where is the client currently?
Please check each box that accurately describes the client being referred (and describe in detail below):
Currently: Inappropriate sexual behaviorsLegal involvementFire settingToileting problemsSubstance abuseSuicidal behaviorPhysical aggression towards othersProperty destructionMultiple placementsIEP/School needs
Previously: Inappropriate sexual behaviorsLegal involvementFire settingToileting problemsSubstance abuseSuicidal behaviorPhysical aggression towards othersProperty destructionMultiple placementsIEP/School needs
Preferred number/gender of treatment parents in the home? This is absolutely required I prefer it, but have some flexibility
Preferred number, age, gender of other kids in the home? This is absolutely required I prefer it, but have some flexibility
Is there a concern about pets being in the home? This is absolutely required I prefer it, but have some flexibility
Does the child require a private room, or is he or she able to share a room with another child? This is absolutely required I prefer it, but have some flexibility
Is the location of the home a factor? Please note preferred counties or regions. This is absolutely required I prefer it, but have some flexibility
School preference (public school in the area of identified foster home or day treatment? This is absolutely required I prefer it, but have some flexibility
Long-term plan for the child (adoption, etc.):
Other pertinent info (please include a description of client's current behaviors and triggers):
