Youth’s Name: Click here to enter text.
Date: Click here to enter a date.
Person Completing Form/Agency: Click here to enter text.
Lynchburg Youth Group Home
Application for Admission
Age: / Choose an item. / DOB: / xx/xx/xx / DJJ#: / Click here / SSN: / xxx-xx-xxxx /
Present Location: / Click here to enter text. / Phone: / xxx-xxx-xxxx /
Home Address: / Click here to enter text. / Phone: / xxx-xxx-xxxx /
Family/Guardian Information (Check box of Guardian)
☐ / Father / ☐ / Mother
Name / Click here to enter text. / Click here to enter text. /
Address / Click here to enter text. / Click here to enter text. /
Phone #s / H: / Phone / W: / Phone / C: / Phone / H: / Phone / W: / Phone / C: / Phone /
Legal Guardian, if not listed above: / NA /
Address: / NA / Phone: / NA /
Comments: / NA /
Referring Agency
☐ / CSU / ☐ / DSS / ☐ / Other (specify): / NA /
Agency Contact: / Click here to enter text. / Phone #: / Phone /
Jurisdiction/Locality
☐ / City of Lynchburg (680) / ☐ / Amherst County (009) / ☐ / Appomattox County (011)
☐ / City of Roanoke (770) / ☐ / Bedford County (019) / ☐ / Campbell County (031)
☐ / Charlotte County (037) / ☐ / Nelson County (125) / ☐ / Roanoke County (161)
☐ / Other (specify): / NA /
Legal History
Pending Charges/Offense Code / Pending Charges/Offense Code
NA / NA
NA / NA
If a violation, what was the original charge & code? / NA /
Past legal history: / NONE /
Next Court Date: / Click here / Time: / Click here / ☐ / am / ☐ / pm / Place: / Choose an item. /
Type
☐ / Detention / ☐ / Shelter Care / ☐ / Advisement / ☐ / Adjudication / ☐ / Dispositional
Referral Information
Physical Needs
Does this youth have any special physical needs that need to be considered if placed? (i.e deaf) / ☐ / Yes / ☐ / No
If YES, please describe: / NA /
Educational/Vocational Needs
Is the youth currently enrolled in school? / ☐ / Yes / ☐ / No
If NO, is the youth eligible to return to school? / ☐ / Yes / ☐ / No
Current/Last School: / Click here to enter text. / Last Grade Completed: / Choose /
Special Education Needs? / ☐ / Yes / ☐ / No
If YES, please describe: / NA /
Is the youth currently employed? / ☐ / Yes / ☐ / No
If YES, where: / NA /
Has the youth had prior employment? / ☐ / Yes / ☐ / No
If YES, please describe: / NA /
Mental Health/Emotional/Psychological Needs
Does the youth have special needs? / ☐ / Yes / ☐ / No
If YES, please describe: / NA /
Health Needs
Does the youth have any special health needs? (i.e. chronic health conditions, illnesses, injuries, or allergies) / ☐ / Yes / ☐ / No
If YES, please describe: / NA /
Does the youth have any immunizations needs? / ☐ / Yes / ☐ / No
If YES, please describe: / NA /
Protection Needs
Are there any special protection needs for this youth? / ☐ / Yes / ☐ / No
If YES, please describe: / NA /
PREA
In the interest of sexual safety, Lynchburg Juvenile Services will follow all standards of the Prison Rape Elimination Act (PREA).
Therefore, please indicate if the youth is gender non-conforming? / ☐ / Yes / ☐ / No
If YES, please describe: / NA /
Suitability
Do you have any concerns about the suitability to placement of the youth? / ☐ / Yes / ☐ / No
If YES, please describe: / NA /
Reasons for Referral
1) / What factors exist at this time that prompted referral for placement?
Click here to enter text. /
2) / What will you likely recommend if the youthis not accepted by Opportunity House?
Click here to enter text. /
3) / Are the family/guardian and the youth aware of this referral? / ☐ / Yes / ☐ / No
Assessment of Youth for Treatment Planning
☐ / Note: In lieu of completing this section, I have completed the ASSESSMENT CHECKLIST and attached it to this form.
Youth’s Strengths / Youth’s Weaknesses
1) / NA / 1) / NA /
2) / NA / 2) / NA /
3) / NA / 3) / NA /
4) / NA / 4) / NA /
Recommended Goals for Treatment
1) / NA /
2) / NA /
3) / NA /
4) / NA /
Comments: / NA /
The following information is also needed, if available:
School transcripts including the current IEP
Psychological Reports
Counseling/Mental Health Summaries
Medical Summaries
Prior Placement Summaries
The DJJ Risk Assessment (if completed)
The Assessment Checklist (next page of this form)
FAPT Referral and Summary; CANS
CAFAS
Probation/Parole Plan
The parent/guardian and youth will need to be interviewed, if possible, at the facility.
Prior to admission of the accepted youth the following information is also needed:
Birth Certificate or Registration Card
Social Security Card
Health/Dental Insurance Information
Immunization Record (may be included in school or medical file)
Current Physical (please request form, if needed)
______
Signature of Person Completing Referral Date
Lynchburg Youth Group Home Assessment Checklist
Signature of Person Completing Assessment: / Relationship: / Click here /☐ / Youth / ☐ / Parent/Guardian / ☐ / Caseworker / ☐ / Probation Officer
☐ / Social Worker / ☐ / Other (specify): / NA /
Strengths
☐ / Polite/Sociable / ☐ / Cheerful/Easy Going / ☐ / Intelligent / ☐ / Healthy
☐ / Kind/Caring/Helpful / ☐ / Honest/Trustworthy / ☐ / Reads Well / ☐ / Athletic
☐ / Non-aggressive / ☐ / Sociable / ☐ / Good Math Skills / ☐ / Substance Free
☐ / Respectful / ☐ / Positive Leader / ☐ / Follows Directions / ☐ / Hobbies
☐ / Positive Values / ☐ / Assertive / ☐ / On Grade Level / ☐ / Mechanical
☐ / Determined / ☐ / Positive Peer Group / ☐ / Supportive Family / ☐ / Artistic
☐ / Sense of Humor / ☐ / Respects Property / ☐ / Positive Friends / ☐ / Creative
☐ / Mature / ☐ / Organized Sports / ☐ / Hard Working / ☐ / Musical
☐ / NA / ☐ / NA / ☐ / NA / ☐ / NA /
Concerns
☐ / Substance Use / ☐ / Impulsive / ☐ / Parenting Skills / ☐ / Unresolved Grief
☐ / Lacks Remorse / ☐ / Withdraws / ☐ / Truancy / ☐ / Risk Taking Behavior
☐ / Accident Prone / ☐ / Low Self-esteem / ☐ / Poor Grades / ☐ / Suicidal
☐ / Negative Leadership / ☐ / Follower / ☐ / Argues / ☐ / Blames Others
☐ / Blows-up / ☐ / Picks/Teases/Provokes / ☐ / Poor Decision Making / ☐ / Lying/Dishonest
☐ / Sad/Unhappy / ☐ / Aggressive / ☐ / Threatens/Bullies / ☐ / Non-Assertive/Victim
☐ / Lazy / ☐ / Steals / ☐ / Poor Manners/Rude / ☐ / Damages Property
☐ / Rebellious / ☐ / Curses / ☐ / Limited Leisure Outlets / ☐ / Physical Fights
☐ / Manipulative / ☐ / Gang Member / ☐ / Criminal Values / ☐ / Bossy/Pushy
☐ / NA / ☐ / NA / ☐ / NA / ☐ / NA /
Suggested Service Needs
☐ / Delinquent Free/Crime Free Behavior / ☐ / Life/Independent Living Skills
☐ / Substance Education / ☐ / Social Skills/Manners
☐ / Substance Treatment / ☐ / Anger Management
☐ / Emotional Regulation / ☐ / Restorative Justice/Restitution
☐ / Work/Community Service / ☐ / Family Counseling
☐ / Mental Health Counseling / ☐ / Health/Dental Care: / NA /
☐ / Participate in Approved School Plan / ☐ / Good Decision Making Skills
☐ / Loss/Grief Work / ☐ / Teen Parenting
☐ / Cooperation/Respect for Authority / ☐ / Positive Leadership
☐ / NA / ☐ / NA /