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Emergency Placement
Emergency Placement Form
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-
Step
1
of 3
Date / Time
Date
Time
How were you referred to HOC?
Online
Professional/Coworker
Residential Coordinator
Youth's Current Placement
Other
Professional's name, agency, title
Professional's Phone Number
Professional's Email
*
Explain how you were referred
Youth's Name
Age
Name of youth's current placement
Which type of placement is desired?
Level 3 Residential
Emergency/Shelter (Temporary)
Emergency with Possible Admission to Residential
Specify timeframe placement is needed
Next
Reason for Referral (why is emergency placement needed today?)
Youth's Background Information
Why in care? Describe personality, strengths, weaknesses, share concerns, and ways we could help limit issues
Behaviors (History or behavior that has been displayed in the last 90 days)
Physical/Verbal Aggression
Substance Abuse
Theft/Stealing
Sexual Misconduct
Elopement/Running Away
Struggles with Boundaries
Self-Harm
Difficulty with Authority
Fire Setting
Criminal Activity/Charges
Explain physical/verbal aggression
Explain substance abuse
Explain theft/stealing
Explain sexual misconduct
Explain elopement/running away
Explain difficulty with authority
Explain struggles with boundaries
Explain self-harm
Explain fire-setting
Explain criminal activity/charges
Does the youth show a need for a single bedroom?
Yes
No
Please explain
Current School
Grade Level
Does the youth have an IEP or 504 plan?
Yes, the youth has an IEP or 504 plan
No, but the youth shows a need for additional support
No
Are there any long term suspensions/expulsions in place
Yes
No
Not currently but in the past
Next
Does the youth have any medical conditions that may require extra support?
Yes
No
Describe medical conditional and accommodations that may be needed.
Is the youth currently taking medications?
Yes
No
Other
Does not apply
Please write any additional notes here
Submit
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