IFCS Application for Services
THIS BOX FOR IFCS USE ONLY
Regional Info:
Date Received:
Start Date:
Client Name:
IFCS Record ID #:
Funding Agency:
Place on the Waiting list
Not appropriate for services
DOB: 00/00/0000
Age:
Race:
Medicaid #:
Insurance ID #:
Client ID# used by Referring Agency
SS #:
Caregiver at Intake: Name
Sex:
(only if required by contract)
Relationship:
Phone #: 000/000/0000
(who has physical custody of child)
Address:
Is this the legal Guardian:
Address:
Referral Source Agency:
Mailing Address:
Office #: 000/000/0000
Yes 

No

Home #: 000/000/0000
Work #: 000/000/0000
Relationship:
Home #: 000/000/0000
Work #: 000/000/0000
Contact Person:
E-mail Address:
If no, who is?
Fax #: 000/000/0000
REASON FOR REFERRAL (check the general problem/problems that prompted this referral. Check all that apply.)
Abuse/Neglect
School Problems
Substance Abuse
Infant Mental Health
Domestic Violence
Juvenile Delinquency
Physical Problems
Other (explain)
Trauma
Sex Offender
Mental Health/Emotional Problems
DIAGNOSTIC INFORMATION:
No diagnosis assigned
Date of Diagnosis: 00/00/0000
Current Medications:
Please add number and description:
Axis I:
Axis II:
Information unknown
Not required
Axis III:
Axis IV:
Axis V:
PLACEMENT RISK:
Not at risk of placement
Is the client (check one):
 At risk of an out of home placement
Returning home from an out of home placement
 Currently in an out of home placement  is the goal to return client to home/community?
Check the type of placement:
Foster Care
Relative
Youth Academy/Training Center
Secure Detention
Group Home
Residential Treatment Facility
Other (specify)
If applicable, how great is the risk of out of home placement?
Low
Moderate
High


Yes 
No

Psychiatric Hospitalization
Respite/ Emergency Shelter
Placement Pending
PLACEMENT HISTORY: (check type of placement and number of separate placements of that type)
No history of placements
Placement Type
Foster Care
Relative
Psychiatric Hospitalization
Other (specify)
How Many Times?
Placement Type
Group Home
Residential Treatment Facility
Respite/ Emergency Shelter
Does this client have any previous or current DJJ/DJS involvement? Yes 
No
If applicable, enter current charge(s)
(If yes, check all DJJ/DJS placement history that applies)
Is this client adjudicated delinquent?

Placement Type
No previous DJJ placements
Probation
Group Home
Long Term Secure Confinement
Secure Detention
Other (specify)
# of placements
How Many Times?

Yes 

No

Check all applicable behaviors or history of:
Aggressive/Violent
Sex Offender
Drug possession/distribution
Substance Abuse
Theft/other non-violent not listed
Gang involvement
Status Misdemeanors
Repeat offender (more than one incident)
Signature of authorized referral source/representative: ____________________________________________________ Date:
IFCS Application for Services updated 8/2011
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