Date / Time
How were you referred to HOC?
Youth's Current Placement
Professional's name, agency, title
Which residential coordinator?
Name of youth's current placement
Explain how you were referred
Point of Contact
Which type of placement is desired?
Level 3 Residential
Emergency with Possible Admission to Residential
Specify timeframe placement is needed
Date of Birth
What gender does the youth identify as?
What was the gender assigned at birth?
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)
Struggles with Boundaries
Difficulty with Authority
Explain physical/verbal aggression
Explain substance abuse
Explain sexual misconduct
Explain elopement/running away
Explain struggles with boundaries
Explain difficulty with authority
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
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?
Describe why an alternative learning environment may be needed
Are there any long term suspensions/expulsions in place
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)
Does the youth have any medical conditions that may require extra support?
Describe medical conditional and accommodations that may be needed.
Does the youth display a need for psychiatric services?
Is the youth medication compliant?
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
Honoring a Heart of Compassion...Opal Zucca
22 Jun, 2021
New Home, New Chapter
4 Dec, 2020
Christmas Traditions at HOC
30 Oct, 2020
Do you know a youth in need?
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Grandview, Missouri 64030
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