Request for Services Form version 3.0

4. Student Information

6. Last Name:*

7. First Name:*

8. Middle Initial:

10. Race:*

    1. African American
    2. American Indian/Alaskan
    3. Asian
    4. Latino
    5. White
    6. Other
    7. Unknown

11. Sex:*

    1. Male
    2. Female

12. Date of Birth:*
    Date of Birth:

13. Child's Phone number*

    Numbers only.

15. Child's Address*

17. Address2

19. City

20. State

21. Zip

25. Referral Recommendation Originating Source

27. First Name:*

28. Last Name:*

29. Today's Date:*
    Today's Date:

31. Contact Information of Referral Source:*

    Phone number (XXX-XXX-XXXX).

32. E-mail:*

33. Role of Referral Source to Youth:*

    1. CASA
    2. Crossover
    3. Education Specialist
    4. Foster Parent
    5. LCCS
    6. Principal (not a single point of contact)
    7. Single Point of Contact
    8. Teacher (not a single point of contact)
    9. Probation Officer
    10. Other

34. Other:*

38. Education

40. Education Grade*

    1. preschool
    2. kindergarten
    3. 1st
    4. 2nd
    5. 3rd
    6. 4th
    7. 5th
    8. 6th
    9. 7th
    10. 8th
    11. 9th
    12. 10th
    13. 11th
    14. 12th

41. Name of School*
    -- Select One --Crossgates PreschoolDeVilbiss PreschoolArlington Elementary SchoolBeverly Elementary SchoolBirmingham Elementary SchoolBurroughs Elementary SchoolByrnedale Elementary SchoolChase STEM AcademyDeVeaux Elementary SchoolEast Broadway Elementary SchoolEdgewater Elementary SchoolElla P. Stewart Academy for GirlsElmhurst Elementary SchoolGarfield Elementary SchoolGlendale-Feilbach Elementary SchoolGlenwood Elementary SchoolGrove Patterson AcademyHarvard Elementary SchoolHawkins Elementary SchoolKeyser Elementary SchoolLarchmont Elementary SchoolLeverette Elementary SchoolLongfellow Elementary SchoolMarshall Elementary SchoolMartin Luther King, Jr. Academy for BoysMcKinley Elementary SchoolMcTigue Elementary SchoolNavarre Elementary SchoolOakdale Elementary SchoolOld Orchard Elementary SchoolOld West End AcademyOttawa River Elementary SchoolPickett AcademyRaymer Elementary SchoolReynolds Elementary SchoolRiverside Elementary SchoolRobinson Elementary SchoolRobinson Achievement CenterWestfield Achievement AcademyRosa Parks Elementary SchoolSherman Elementary SchoolSpring Elementary SchoolWalbridge Elementary SchoolWhittier Elementary SchoolBowsher High SchoolJones Leadership AcademyRogers High SchoolScott High SchoolStart High SchoolToledo Early College High SchoolToledo Technology AcademyWaite High SchoolWoodward High SchoolOther

    Name of school youth attends.

42. Special Education:*

    1. Yes
    2. No

    Is the youth in special education?

43. IEP:*

    1. Yes
    2. No

    Does the youth have an Individual Education Plan?

47. Reason for referral:*

51. Recommendation Information
    For internal use only.

    For internal use only.

53. Juvenile Court Youth I.D. No.:

55. Recommendation(s) Made:

    1. AOD Services
    2. Collaborative Meetings
    3. Continue with Current Services
    4. Crossover Process
    5. Mediation
    6. Mental Health Services
    7. Mentoring Services
    8. School Stability
    9. Transportation Services
    10. Trauma Education
    11. Trauma Services
    12. Truancy Prevention Services
    13. Tutoring Services
    14. Pending
    15. Other

56. Assessment:

    1. Yes
    2. No

57. Terminated Date:
    Terminated Date:

59. Did you advocate for the youth?

    1. Yes
    2. No

    Did the social worker advocate for current services with the youth? Intended as a follow-up to continue with current services.

60. Continue with Current Services Notes:

    What types of services are the youth already linked with? May include name(s) of agency/agencies.

64. Follow-Up
    For internal use only.

    For internal use only.

66. AOD Recommendation Date:
    AOD Recommendation Date:

67. AOD Services Date of Linkage:
    AOD Services Date of Linkage:

    If yes, when did linkage occur?

68. AOD Services Linkage Made:

    1. Yes
    2. No

72. Collaborative Meetings Recommendation Date:
    Collaborative Meetings Recommendation Date:

73. Collaborative Meetings Date of Linkage:
    Collaborative Meetings Date of Linkage:

    If yes, when did linkage occur? Occurrence 1

74. Collaborative Meetings Date of Linkage:
    Collaborative Meetings Date of Linkage:

    Occurrence 2

75. Collaborative Meetings Date of Linkage:
    Collaborative Meetings Date of Linkage:

    Occurrence 3

77. Collaborative Meetings Date of Linkage:
    Collaborative Meetings Date of Linkage:

    Occurrence 4

78. Collaborative Meetings Date of Linkage:
    Collaborative Meetings Date of Linkage:

    Occurrence 5

79. Collaborative Meetings Date of Linkage:
    Collaborative Meetings Date of Linkage:

    Occurrence 6

80. Collaborative Meetings Date of Linkage:
    Collaborative Meetings Date of Linkage:

    Occurrence 7

82. Collaborative Meetings Date of Linkage:
    Collaborative Meetings Date of Linkage:

    Occurrence 8

83. Collaborative Meetings Date of Linkage:
    Collaborative Meetings Date of Linkage:

    Occurrence 9

84. Collaborative Meetings Date of Linkage:
    Collaborative Meetings Date of Linkage:

    Occurrence 10

85. Collaborative Linkage Made:

    1. Yes
    2. No

89. Continue with current services Recommendation Date:
    Continue with current services Recommendation Date:

90. Continue with current services Date of Linkage:
    Continue with current services Date of Linkage:

    If yes, when did linkage occur?

91. Continue with current services Linkage Made:

    1. Yes
    2. No

93. Crossover Process Recommendation Date:
    Crossover Process Recommendation Date:

94. Crossover Process Date of Linkage:
    Crossover Process Date of Linkage:

    If yes, when did linkage occur?

95. Crossover Process Linkage Made:

    1. Yes
    2. No

97. Mediation Recommendation Date:
    Mediation Recommendation Date:

98. Mediation Date of Linkage:
    Mediation Date of Linkage:

    If yes, when did linkage occur?

99. Mediation Linkage Made:

    1. Yes
    2. No

101. Mental Health Services Recommendation Date:
     Mental Health Services Recommendation Date:

102. Mental Health Services Date of Linkage:
     Mental Health Services Date of Linkage:

     If yes, when did linkage occur?

103. Mental Health Services Linkage Made:

     1. Yes
     2. No

105. Mentoring Services Recommendation Date:
     Mentoring Services Recommendation Date:

106. Mentoring Services Date of Linkage:
     Mentoring Services Date of Linkage:

     If yes, when did linkage occur?

107. Mentoring Services Linkage Made:

     1. Yes
     2. No

109. School Stability Recommendation Date:
     School Stability Recommendation Date:

110. School Stability Recommendation Date of Linkage:
     School Stability Recommendation Date of Linkage:

     If yes, when did linkage occur?

111. School Stability Linkage Made:

     1. Yes
     2. No

113. Transportation Recommendation Date:
     Transportation Recommendation Date:

114. Transportation Services Date of Linkage:
     Transportation Services Date of Linkage:

     If yes, when did linkage occur?

115. Transportation Services Linkage Made:

     1. Yes
     2. No

117. Trauma Education Recommendation Date:
     Trauma Education Recommendation Date:

118. Trauma Education Date of Linkage:
     Trauma Education Date of Linkage:

     If yes, when did linkage occur?

119. Trauma Education Linkage Made:

     1. Yes
     2. No

121. Trauma Services Recommendation Date:
     Trauma Services Recommendation Date:

122. Trauma Services Date of Linkage
     Trauma Services Date of Linkage

     If yes, when did linkage occur?

123. Trauma Services Linkage Made:

     1. Yes
     2. No

125. Truancy Prevention Services Recommendation Date:
     Truancy Prevention Services Recommendation Date:

126. Trauma Recommendation Term Date:
     Trauma Recommendation Term Date:

     If yes, when did linkage occur?

127. Truancy Prevention Services Linkage Made:

     1. Yes
     2. No

129. Tutoring Services Recommendation Date:
     Tutoring Services Recommendation Date:

130. Tutoring Services Date of Linkage:
     Tutoring Services Date of Linkage:

     If yes, when did linkage occur?

131. Tutoring Services Linkage Made:

     1. Yes
     2. No

133. Pending Recommendation Date:
     Pending Recommendation Date:

134. Pending Date of Linkage:
     Pending Date of Linkage:

     If yes, when did linkage occur?

135. Pending Linkage Made:

     1. Yes
     2. No

136. Termination Codes

     1. (U) Unsuccessful
     2. (S) Successful
     3. (O) Other

     Unsuccessful = we were unable to engage the key players | Successful = We were able to engage the key players and the team was able to make a decision | Other = It was an inappropriate referral

138. Comments:

     If no, why wasn't linkage made? Please be detailed yet concise. Please include ALL service(s) where linkage was not made.

142. Incentive:

     1. Yes
     2. No

     Incentive given?

146. Notes:

     Date, contact, and content.

148. First Name:

     Contact Information 1:

149. Last Name:

151. Phone number:

     xxx-xxx-xxxx

152. E-mail:

153. Role to child:

155. First Name:

     Contact Information 2:

156. Last Name:

158. Phone number:

     xxx-xxx-xxxx

159. E-mail:

160. Role to child:

162. First Name:

     Contact Information 3:

163. Last Name:

165. Phone number:

     xxx-xxx-xxxx

166. E-mail:

167. Role to child:

169. First Name:

     Contact Information 4:

170. Last Name:

172. Phone number:

     xxx-xxx-xxxx

173. E-mail:

174. Role to child:

176. First Name:

     Contact Information 5:

177. Last Name:

179. Phone number:

     xxx-xxx-xxxx

180. E-mail:

181. Role to child:

185. Youth: Change of Address
     For internal use only.

     For internal use only.

187. Address1

     Youth Address: Change 1

189. Address2

191. City

192. State

193. Zip

195. Date of Address Change Entry:
     Date of Address Change Entry:

     Change 1

197. Address1

     Youth Address: Change 2

199. Address2

201. City

202. State

203. Zip

205. Date of Address Change Entry:
     Date of Address Change Entry:

     Change 2

Leave This Blank:


207. 1. Receive an email copy of this form.
208. Email address

     This field is not part of the form submission.

209. Submit

* indicates a required field