Referring Persons Name:
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Email Address:
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Agency Name (if applicable):
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Person Making this referral: |
Parent:
Court:
Agency:
Other: |
Relationship to child:
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Address:
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City, State:
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Zip/Postal Code:
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What is the best time for us to contact you regarding this referral?
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How did you find out about Hope Harbor?
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Child's name
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Sex
Male:
Female: |
Age
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Grade
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Who has legal custody?
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Briefly tell us what happened that led you to contact us.
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| Check all that apply to the child in question: |
Abused:
Emotionally
Physically
Sexually |
Runs Away
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Regresses
(pouts, sucks thumb, wets) |
Unresolved issues |
Losses
(death, illness, divorce,
moves, incarceration) |
Physically handicapped |
School problems |
Short attention span
(ADD/ADHD) |
Acts out sexually |
Fights, hits, kicks |
Suicidal (plans or attempts) |
Threatens authority or peers |
Defiant/ manipulates
authority or peers |
Destructive |
Alcohol/ drugs/ tobacco |
Steals/ lies |
Truant |
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Any other information that you
believe is important for us to know:
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