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Placement Consultation
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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
Which residential coordinator?
Name of youth's current placement
Explain how you were referred
Placement Agency
Point of Contact
Title/Relationship
Phone Number
Email
*
Which type of placement is desired?
Level 3 Residential
Emergency/Shelter (Temporary)
Emergency with Possible Admission to Residential
Specify timeframe placement is needed
Next
Youth's Name
Age
Date of Birth
What gender does the youth identify as?
What was the gender assigned at birth?
Current Placement
When is placement needed by?
Reason for Referral (program completion, disruption, etc)
Youth's Background Information
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 struggles with boundaries
Explain self-harm
Explain difficulty with authority
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
Specify which support is provided and why
Explain why additional services may be needed
Describe the youth's behavior and performance at school.
Does the youth show a need for an alternative learning environment?
Yes
No
Describe why an alternative learning environment may be needed
Are there any long term suspensions/expulsions in place
Yes
No
Not currently but in the past
Describe the behavior/incident that led to this consequence
Describe the behavior/incident that led to this consequence (history)
Next
Does the youth have any medical conditions that may require extra support?
Yes
No
Describe medical conditional and accommodations that may be needed.
Does the youth display a need for psychiatric services?
Is the youth medication compliant?
Yes
No
Other
Does not apply
Explain lack of medication compliance
Please provide insight
What are the youth's strengths and areas of potential?
Please write any additional notes here
Submit
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