Emergency Placement Form
Date / Time
How were you referred to HOC?
Youth's Current Placement
Professional's name, agency, title
Professional's Phone Number
Explain how you were referred
Name of youth's current placement
Which type of placement is desired?
Level 3 Residential
Emergency with Possible Admission to Residential
Specify timeframe placement is needed
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)
Struggles with Boundaries
Difficulty with Authority
Explain physical/verbal aggression
Explain substance abuse
Explain sexual misconduct
Explain elopement/running away
Explain difficulty with authority
Explain struggles with boundaries
Explain criminal activity/charges
Does the youth show a need for a single bedroom?
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
Are there any long term suspensions/expulsions in place
Not currently but in the past
Does the youth have any medical conditions that may require extra support?
Describe medical conditional and accommodations that may be needed.
Is the youth currently taking medications?
Does not apply
Please write any additional notes here
Honoring a Heart of Compassion...Opal Zucca
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New Home, New Chapter
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Christmas Traditions at HOC
30 Oct, 2020
Do you know a youth in need?
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13900 Southern Rd
Grandview, Missouri 64030
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