Referral Date *

MM

DD

YYYY

EFC Worker Phone # *

(###)

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Supervisor Phone # *

(###)

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IL Phone # *

(###)

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Supervisor Phone # *

(###)

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Client Date of Birth *

MM

DD

YYYY

Client Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Client Phone # *

(###)

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Client Sex *

Male

Female

Contact Person Phone # *

(###)

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Date Client aged out of custody of state *

MM

DD

YYYY

Is the young adult a parent? *

Yes

No

Is client receiving: *

Diploma

GED

Certificate of Completion

Does the client have a disability? *

Yes

No

Is the client willing to comply to the guidance of H2O Ministries? *

Yes

No

Does the client own their own vehicle? *

Yes

No

If not, will transportation be needed?

Yes

No

Please check all applicable: *

Developmental Disability

Developmental Disability: Current Diagnosis is unknown

Serious Mental Health Issues: Suicidal Ideation

Serious Mental Health Issues: Suicidal Attempt

Serious Mental Health Issues: History of Cutting

Serious Mental Health Issues: Current Diagnosis is unknown

Delinquency/Criminal Behavior: History within 3 years

Delinquency/Criminal Behavior: History within 1 year

Delinquency/Criminal Behavior: Acute-history within 60 days

Delinquency/Criminal Behavior: Unknown

Current Drug/Alcohol Abuse: History within 3 years

Current Drug/Alcohol Abuse: History within 1 year

Current Drug/Alcohol Abuse: Acute-History within 60 days

Current Drug/Alcohol Abuse: Unknown

History of Physical Violence: History within 3 years

History of Physical Violence: History within 1 year

History of Physical Violence: Acute-history within 60 days

History of Physical Violence: unknown

Victim of Human Trafficking: Confirmed

Victim of Human Trafficking: Suspected

Victim of Human Trafficking: History within 3 years

Victim of Human Trafficking: History within 1 year

Victim of Human Trafficking: Acute-history within 60 days

Victim of Human Trafficking: Unknown

DCFS Worker Signature *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Time *

Hour

Minute

Second

AM PM