Application for Intensive In-Home Services Eliada Homes, Inc. "*" indicates required fields Student InfoStudent Name* Preferred Name* Date of Birth* Age* Race* SSN* Gender* Preferred Pronouns Current Living Arrangement* Legal CustodianCustodian Name* Phone* Email* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent Legal Guardian is Parent Parent Name Phone Email Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Notes Case Responsible AgencyCase Responsible Agency* Case Responsible Professional* Email* Phone* Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School PlacementSchool Name* Phone* IEP?*YesNo504?*YesNoHistory of truancy/suspensions or expulsions?*YesNoFunding SourceFunding Source Name* Insurance/Medicaid Number* MCO Record Number* MCOMCO Name* Care Coordinator* Phone* Email* Primary Care PhysicianPhysician Name* Practice* PsychiatristPsychiatrist Name* Practice* Placement/Hospitalization History None Level of Care Admission Date Discharge Date Reason for Placement DJJ Court Counselor None Counselor Name Phone Email Current StatusCurrent behaviors/presenting problems and reason for referral*Primary DiagnosesPrimary Diagnoses* Date* By Whom?* Additional DiagnosesAdditional Diagnoses Date By Whom Additional Diagnoses Date By Whom Additional Diagnoses Date By Whom MedicationsMedication Dose Frequency Medication Dose Frequency Medication Dose Frequency Medication Dose Frequency Medication Dose Frequency Is the student compliant with medications? Current StressorsLegal Problems*YesNoDescribe Physical Assault*YesNoDescribe Addiction*YesNoDescribe Medical Problems*YesNoDescribe Relationship Problems*YesNoDescribe Abuse History*YesNoDescribe Sexual Assault/Rape*YesNoDescribe Separation/Loss*YesNoDescribe Self-Injurious/Suicidal Behaviors*YesNoDescribe Substance Use History*YesNoDescribe Sexualized Behaviors*YesNoDescribe Psychotic Behaviors*YesNoDescribe Other*YesNoDescribe Consent* Family has been notified and agrees to the referralCommentsThis field is for validation purposes and should be left unchanged.
