Phone:(704) 898-2618
Fax:(704) 869-6029

Treatment Foster Care Matching Criteria

    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

    Placement Criteria

    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):

    [recaptcha]