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As the parent, legal guardian and/or placing agency
representative, I am requesting consideration for services of
Presbyterian Homes & Family Services, Inc. for out of home
placement to assist me/us in meeting the needs of:
for whom I/we have legal custody,. The information
shared/provided shall be accurate to the best of my/our
knowledge and accurately reflect the needs of this child.
Throughout the application process and placement of this
child, I will make every effort to cooperate, assist, and
participate in the application, planning and services that may
be provided. |
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Campus Of
Interest: |
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Child's Date of
Birth: |
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Placement
Services Requested: |
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Placement Date
(anticipated): |
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Length of
Placement (projected): |
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Please answer or
provide information that will answer each of the following:
All Fields
Required |
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Why are you
requesting out of home services? |
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What specific
physical needs does this child present? |
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What educational
needs does this child have? |
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What mental
health, emotional and/or psychological needs does this child
present? |
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What health care
needs does this child require? |
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What
protection/supervision needs this child require? |
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Why do you feel
this facility is suitable for this child? |
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Does the
admission of this child present any significant risk to
him/her? |
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Does the
admission of this child present any risk to other residents or
staff? |
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What are the
short & long term discharge plans for this child? |
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Your assistance and support throughout the application process
are required so that Presbyterian Homes & Family Services can
secure documentation, information and records from various
resources that will assists in determining need for placement,
appropriateness of placement and for the development of a plan
for care and treatment. |
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Your Name: |
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Date: |
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Street Address: |
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City: |
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State: |
Zip: |
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Organization or
Agency: |
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Your Phone Number: |
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Access Code |
Type Access Code Here
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If you encounter a form submission
error a Refresh
of the access code is
required.
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