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2018 LSSNCA - Youth Haven Agency Referral
Walking with families affected by social stigma to raise up young people who are connected, healthy, and succeeding.
Email address *
CLIENT BACKGROUND
*Please send participant’s most recent physical exam/health certificate
**Please send participant’s most recent labs
Briefly describe the camper’s Living Situation And Social History. Please include care taker status, deaths and serious illness in the family, and behavior patterns. *
Your answer
Vulnerability: What current stressors or history of trauma(s) are present in the persons life (e.g., living with HIV, a family member is HIV-positive, substance use, mental health diagnosis, foster care, resettled refugee, homelessness, interpersonal violence, community violence, incarcerated family member)? *
Your answer
How long has this person known about the diagnosis or condition? *
Your answer
Who else in the family is aware about the diagnosis or condition? *
Your answer
Describe any physical, mental, or emotional Limitations and/or special needs (i.e. wheelchair, asthma). Are there additional supports needed for activities? *
Your answer
What Supports are in place to address the young person’s vulnerability (e.g., counseling, extra-curriculum activities, IEP)? *
Your answer
Please list any camps the applicant has attended in the past two years:
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Which program(s) are you referring this participant for: *
Required
Additional Comments:
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BEHAVIORAL HEALTH DETAILS
Applicant Name: *
Your answer
Best way to contact client *
Client Phone Number(s) *
Your answer
Client Email(s) *
Your answer
Date Of Birth: *
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Behavioral Health Conditions
Hyperactivity
Depression
Anxiety
Stress
History of Violence
Anger
Bed wetting
Biting or Aggression
Environment Destruction
Sets Fires
Self-mutilation
Suicidal Ideation
Autism Spectrum
Relationship/Interpersonal Violence
Yes
No
Explanation (YES responses) / Medication / Detail *
Based on responses of Behavioral Health Conditions chart
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If "Yes" to Suicidal Ideation, provide Dates, Resolution:
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Other Important conditions:
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MEDICAL DETAILS
Please write any allergies (FOOD, BEE STINGS, MEDICATIONS, GRASSES, TREES, etc.) as well as any food restrictions (e.g., vegetarian, lactose-intolerant) *
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Is there a prescription for an “EpiPen” for severe allergic reactions? *
Is there a prescription for a rescue inhaler for asthma attacks? *
MEDICATION INFORMATION
For all clients, please send (email: yahyad@lssnca or fax: 202-723-3303) a list of CURRENT medications taken by the applicant (including PRN, over-the-counter drugs, vitamins, experimental medications)
Name of person completing this form: *
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Title of person completing this form: *
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Phone number of person completing this form: *
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Date: *
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