Multi-Agency Alliance for Children, Inc.
CHRIS Kids, Creative Community Services Inc., Devereux, Elks Aidmore Children Center, Georgia Baptist Children’s Homes and Family Ministries, Inc., Hillside, Inc., The Methodist Home for Children and Youth, and Twin Cedars Youth and Family Services, Inc
MAAC Application
1. Youth’s Name:______Date of Application: ______
2. SS# ______3.Date of Birth: ______Age: ______4.Medicaid#: ______
AGENCY INVOLVEMENT
5. Referring Agency type: □DFCS □DJJ □DBHDD □Other______
6. Referring Agency Name: ______
Case Worker Name: ______New Worker: ______
Address: ______Address: ______
City/Zip: ______City/Zip: ______
Phone: ______Phone: ______
Cell: ______Cell: ______
Email: ______Email: ______
Fax: ______Fax: ______
Supervisor Name: ______New Supervisor: ______
Phone: ______Phone: ______
Cell: ______Cell: ______
Email: ______Email: ______
Fax: ______Fax: ______
7. What date did the youth come into care? ______← MANDATORY
month / day / year
8. Gender: □Female □Male
9. Ethnicity: □White □Black/African American □American Indian/Alaskan □Asian or Pacific Islander □Hispanic □Multi-racial (Specify ______) □Other (Specify ______) □Unable to determine
10. Sexual Orientation: □Lesbian □Bisexual □Gay □Transgendered □Questioning □Heterosexual □Unknown
11. Religion: □Protestant □Catholic □Jewish □Muslim □No Affiliation □Other:______
12. Legal Custodian (relationship to child) Mark only one:
□Parents □DJJ □DFCS □Guardianship □Emancipated Minor □Adult □Other □Unknown
Name(s): ______
Address: ______
Phone: ______
13. Is youth in joint custody of DFCS/DJJ? □Yes □No Date of Commitment: ______← MANDATORY
Current Permanency Plan:
□Adoption □Guardianship □ Long Term Foster Care
□Reunification □Living w/ Other Relative □Emancipation
14. Current Placement (Please Circle Applicable Placement)
Rev. 4/2/13 1
Multi-Agency Alliance for Children, Inc.
CHRIS Kids, Creative Community Services Inc., Devereux, Elks Aidmore Children Center, Georgia Baptist Children’s Homes and Family Ministries, Inc., Hillside, Inc., The Methodist Home for Children and Youth, and Twin Cedars Youth and Family Services, Inc
01 Biological Home
02 Adoptive Home
03 Home of Relative
04 Home of Family Friend
05 Independent Living (Friend)
06 Independent Living (Self)
07 Homeless
08 Emergency Shelter (Group)
09 Emergency Shelter (Home)
10 Medical Hospital (Inpatient Physical Health)
11 Residential Job Corps Center
12 Foster Care (Therapeutic/Treatment)
13 Foster Care (Regular/Basic)
14 Foster Care (Specialized DD/Medically Fragile)
15 Group Home (AWO, BWO)
16 Supervised Independent Living (ILP/TLP)
17 Intensive Treatment Unit
18 Outdoor Therapeutic Program (OTP/OCCP)
19 Residential Treatment Center (MWO)
20 Psychiatric Residential Treatment Facility (PRTF)
21 Crisis Stabilization (CSP/CSU)
22 Youth Detention Center (YDC)
23 Jail
24 Drug/Alcohol Rehab Center
25 Runaway/Placement Unknown
26 Respite (Long-Term)
27 Other______
Rev. 4/2/13 1
Multi-Agency Alliance for Children, Inc.
CHRIS Kids, Creative Community Services Inc., Devereux, Elks Aidmore Children Center, Georgia Baptist Children’s Homes and Family Ministries, Inc., Hillside, Inc., The Methodist Home for Children and Youth, and Twin Cedars Youth and Family Services, Inc
Placement / Treatment History: Use the codes above to list the most recent out-of-home placements, AND Attach a Historical Placement Summary.
Code / Placement Name / Beginning Date / Ending Date / Why Youth Left / Youth’s Next Placement15. Has the youth had the following services?
CIRCLE ONE / IF YES, DATE(s) / IF YES, PLACE(s)In-Patient Hospital / YES NO
Crisis Placement / YES NO
ER Involvements / YES NO
S/A Detox Attempts / YES NO
Wrap Services CBAY / YES NO / Which Care Management Entity:
Wrap Services Non-Waiver / YES NO / Which Care Management Entity:
16. List all visiting resources and relationship to client
Name(s) ______Primary Resource? Yes ___ No___
Address ______Relationship to Client ______
Phone #______
Name(s) ______Primary Resource? Yes ___ No___
Address ______Relationship to Client ______
Phone #______
Name(s) ______Primary Resource? Yes ___ No___
Address ______Relationship to Client ______
Phone #______
17. Biological Mother’s rights terminated 18. Biological Father’s rights terminated
or relinquished? or relinquished?
□Yes □No □Yes □No
19. Has child experienced a failed/dissolved adoption? □Yes □No
20. Any birth family contact? □Yes □No
Name(s) ______Phone #______
Address ______Relationship to Client ______
Type of Contact/Frequency: Phone ______Day Visits ______Overnight ______
Name(s) ______Phone #______
Address ______Relationship to Client ______
Type of Contact/Frequency: Phone ______Day Visits ______Overnight ______
Name(s) ______Phone #______
Address ______Relationship to Client ______
Type of Contact/Frequency: Phone ______Day Visits ______Overnight ______
21. Any surrogate family contact? □Yes □No
Name(s) ______Phone #______
Address ______Relationship to Client ______
Type of Contact/Frequency: Phone ______Day Visits ______Overnight ______
Name(s) ______Phone #______
Address ______Relationship to Client ______
Type of Contact/Frequency: Phone ______Day Visits ______Overnight ______
Name(s) ______Phone #______
Address ______Relationship to Client ______
Type of Contact/Frequency: Phone ______Day Visits ______Overnight ______
22. Agency(ies) currently serving youth (mark all that apply)
□DFCS □Substance Abuse □Community Mental Health □DBHDD- BH
□DJJ □Independent Juvenile Court □Private Mental Health □DBHDD- DD
□CME: ______□Other ______
County ______Address ______
JUVENILE JUSTICE INVOLVEMENT
23. History of involvement with Juvenile Justice: Yes□ No□ Current involvement? Yes□ No□
24. Current Juvenile Justice Disposition (mark all that apply):
□Pending □ Informal Adjustment □Probation □Commitment (In Community)
□Commitment (Out of Community) □MH Court □Drug Court
25. Any Arrests in the past 30 days? Yes□ No□ If yes, specify charges______
HISTORY OF MALTREATMENT
26. History of Maltreatment (mark all that apply): □Neglect □Emotional abuse □Physical abuse
□Sexual abuse □Suspected abuse/neglect □Other (specify) ______
27. Parental/Caregiver Issues: □Criminality □Current incarceration □Mental illness/Mental retardation
□Family Violence □Suicide attempts □Death by suicide or homicide
EDUCATIONAL INFORMATION
28. Type of Current School Placement (Please check one)
□Public school □Private school □Home school □Tech/Vocational School
□GED Program □2-year College □4-year College □Home School
□HS Graduate □GED Graduate □College Graduate (Specify: AA,BA)______
□Not enrolled (Reason, if other than graduate) ______
29a. Enrollment Location (Please check one)
□GNET □Alternative □On-Site □General/Mainstream
29b. Enrollment Type (Please check one)
□Regular Education □Regular Education w/ SST/504 Plan □Special Education*
*Does the student have an IEP? □ Yes □ No Date last updated ______
29c. Special Education Eligibility (if applicable)
□Emotional Behavioral Disorder/SED □Autism □Learning Disability
□Mild Intellectual Disability □Mod. Intellectual Disability □Severe Intellectual Disability □Traumatic Brain Injury □Hearing impairment/Deaf □Visual Impairment/Blind □Significant Developmental Delay □Orthopedic Impairment □Speech-Language Impairment
□Other health impairment Specify:______
29d. Class Type (Please check all that apply)
□GED Classes □Gifted Classes □Resource/Other Special Ed. Placement
□Regular Classes □Self-Contained Classroom □Regular Classes w/ Support
30. Speech and Language: Problem identified Yes□ No□ Evaluation completed Yes□ No□
31. School Name: ______Address: ______
Grade Level ______Last grade completed ______Number days missed in the past 30 days: ______
32. Employment: Is the child available for work? Yes□ No□ If not, why not? ______
______
33. IQ Score 35. Adaptive Behavior Scale
(1) Stanford Binet □ (1) Vineland □
(2) Kaufmann Brief Intelligence Test (K-Bit) □ (2) American Association of Mental Retardation □
(3) Weschler Intelligence Scale for Children (WISC) □ (3) Other:______
(4) Weschler Adult Intelligence Scale (WAIS) □ Test#:______
(5) Other: ______Date completed:______
Date of Test______
Full Scale Score: ______36. Achievement Test Score
Verbal Score: ______ (1) Woodcock Johnson (WJR) □
Performance Score: ______ (2) Weschsler (WIAT) □
(3) Peabody (PIAT) □
34. Most current diagnoses: (use “other diagnosis” (4) Wide Range Achievement Test (WRAT) □
or “rule out diagnosis” as needed. Use Code.) (5) Kaufman Test of Educational Achievement Test
Axis I: ______ (KTEA) □
Axis II______(6) Other:______
Axis III______Test#:______
Axis IV______Test#:______
GAF ______
Date of Most Recent Diagnosis: ______Reading:
Grade Level:______
Standard Score:______
Math:
Grade Level:______
Standard Score:______
37. Child Strengths (Interests or Abilities):
_____Artistic _____Humor _____Friendly
_____Personable _____Forms emotional connections _____Affectionate
_____Family Support _____Academics _____Motivated
_____Music/Instruments _____”Street Smart” _____Athletic
_____Communication
Other strengths:______
______
38. Describe situations when child has been most successful: ______
______
39. Identified Family Participating in Treatment (include relatives, mentor, coach, former foster family, adoptive family, birth family and any others participating in treatment): ______
______
40. Who does child identify as family of choice (please include contact info)? ______
______
41. IF APPLICABLE, what is the birth family’s income? ______
42. Describe any cultural or religious considerations/affiliations in treatment: ______
______
43. Please check all services received within last 6 months:
_____Individual Therapy _____Specialized Treatment Services _____Mentoring/Tutoring
_____Community Support _____Crisis Stabilization _____Hospitalization
_____Medication Monitoring _____Specialized Adaptive Devices _____Behavior Aide
_____Special Ed Services _____Advocacy _____Day Treatment
_____Wraparound _____Transportation _____Family Education
_____Respite Services _____Family Intervention/Therapy _____None
Other______Other______
44. Please check all successful interventions:
Rev. 4/2/13 1
Multi-Agency Alliance for Children, Inc.
CHRIS Kids, Creative Community Services Inc., Devereux, Elks Aidmore Children Center, Georgia Baptist Children’s Homes and Family Ministries, Inc., Hillside, Inc., The Methodist Home for Children and Youth, and Twin Cedars Youth and Family Services, Inc
_____Redirection
_____Time out
_____Loss of Privileges
_____Therapeutic Hold
_____Humor/ Distraction
_____Behavior Plan
_____Reward/ Incentives
Other______Other______
Rev. 4/2/13 1
Multi-Agency Alliance for Children, Inc.
CHRIS Kids, Creative Community Services Inc., Devereux, Elks Aidmore Children Center, Georgia Baptist Children’s Homes and Family Ministries, Inc., Hillside, Inc., The Methodist Home for Children and Youth, and Twin Cedars Youth and Family Services, Inc
Other Successful Interventions: ______
______
45. Child/Family’s feeling about transition/treatment: ______
______
46. Does child require assistance with personal care chores? □Yes □No Check all that apply
_____Toileting _____Bathing _____Grooming _____Dressing
Describe other Assistance Needed: ______
______
______
47. Please indicate the child’s history of behaviors:
Difficulty concentrating, restless, impulsive
Underactive, lack energy.
Act disobediently at home.
Acts disobediently at school.
Associates with children who get into trouble.
Doesn’t get along well with other children
Is bullying or mean/gets into fights
Lies and/or cheats.
Feels no guilt after misbehaving
Runs away
Has volatile temper tantrums
Indiscriminately goes with or to unfamiliar adults
Exhibits multiple fears, obsessions and worries
Exhibits insatiable neediness (i.e. clinging behavior.)
Appears cooperative and submissive but usually does not follow through on actions or requests.
Child acts older than chronological age. Attempts to parent other children.
Mood and Anxiety Behaviors
Appears sad, unhappy
Has trouble sleeping
Stares blankly
Expresses feeling worthless or inferior
Withdraws, does not get involved with others
Worries excessively, preoccupied with minor annoyances
Complaint of psychosomatic ailments
Sudden mood changes
Has stopped speaking
Elimination Behaviors
Wets self during day
Wets bed at night
Has bowel movements other than in toilet
Smears or plays with bowel movements or urine
Detached from Reality
Hallucinates
Disorganized or incoherent
Has delusions
Eating Disorders
Compulsive Overeating
Anorexia-child refuses to maintain a minimally normal body weight
Bulimia-child maintains normal body weight through binging and purging
Behaviors / Check if Yes / Dates of Occurrence / Briefly Describe
Sexual Behavior Problems
Sexually Promiscuous
Prostitutes
Sexually provocative
Exhibits self in public
Sexually peeks at others
Masturbates in public
Sexual play with peers
Other sexual problems
Sexual Offending Behaviors
Coerces other children into sexual acts
Sexually molests other children
Has exhibited sexual aggressiveness
Danger to Self
Verbal or physical suicidal threats
Suicidal gestures
Talks about suicide
Serious self-abusive behavior
Places self in dangerous situations
Danger to Others
Exhibits life threatening aggression
Physically aggressive behavior toward a child that results in injury or potential injury
Physically aggressive behavior toward an adult that results in injury or potential injury
Verbally threatens others
Damages or destroys property
Steals
Vandalizes
Is cruel to animals
Carries Weapons
Sets fires
Ritualism
Gang involvement
48. Substance Abuse/Dependence/Use? ______ Type(s): □ Alcohol □Drugs □Both
Name of Substance Used / Route of Administration / Frequency of Use / Age at First Use49. How many treatment episodes has the client received in any drug or alcohol program? ______
50. Please List All Current Medications
Medication / Dosage / Reason51. Allergies/Physical/Medical Conditions: ______
______
52. General Health: □ Good □ Poor Explain:______
______
53. Treating Physician Name: ______ Phone Number: ______
Address: ______
54. Has the child been in a medical facility? □Yes □No
Name of facility: ______Discharge date: ______
Condition(s) treated: ______Aftercare needed:______
55. If you are looking for Therapeutic Foster Care, please complete the below questions:
Please check all that apply:
Cross-Cultural placement is appropriate ______OR Race-specific placement is required ______
Can reside with single parent ______OR Two-parent home is required ______
Can reside with other children ______OR Needs home with no other children ______
Can reside with younger children ______
Can reside with older children ______
56. Any other special requirements regarding type of home: ______
______
57. In your opinion, what would be the “ideal” family that would most appropriately meet this child’s needs? ______
______
58. How does the child feel about going into a Therapeutic Foster Care Family? (please specify)
______
59. What is the plan for visitation and/or reunification once the child is placed? ______
60. Would it be necessary for the child to be placed in close proximity to his/her family? □Yes □No
If so, where? ______
61. Plan for Stepdown from Current Services
What type of placement are you interested in?
□TLP/ILP □TFC/SFC □Group Home □Residential Treatment □PRTF □Other ______
Please Submit the Following Documents with this Application:
Date Received
Current Psychological ______
Current Psychosexual (if applicable) ______
Current IEP (if applicable) ______
Rev. 4/2/13 1