Submitting...Validating Captcha...Authenticating...An error has occured. Details of this error have been logged.Submission Success!Referring AgencyName of Agency*Name of Referrer*Email*Phone*Child/AdolescentChild/Adolescent Name*Address*City*StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherZipAge*GenderDate of Birth*Social Security NumberParent/Guardian Contact InformationParent/Guardian NameAddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherZipPhoneEmailCustodyIs this child in custody of DSS?*YesNoHave parental rights been terminated*YesNoChild/Adolescent's Current Placement*HomeHospitalDetention CenterOtherIf other, please explainReimbursementReimbursement Type*VA Medicaid/NumberCSAIV-EAdoption Subsidy/LocalityPrivate InsuranceIEP*YesNoDate of Current IEPGradeSchoolFSIQDocument UploadPLEASE UPLOAD as many of the following documents as possible:Most recent psychological evaluation and psychiatric evaluation. Discharge summaries from previous treatment providers within last year. Social history – Pre/Post Dispositional Report - Foster Care Service Plans. Documents with Information describing behavior within past 2 months (treatment plans, nursing/progress notes, progress summary reports) indicating medical necessity for secure RTC treatment.Brief description of files being uploadedDocumentCombined total of all files may not exceed 7MB.RemoveAdd Another (9 remaining)
