Just Care For Kids Services Access Trouble Ticket YOUR FIRST NAME LAST NAME TITLE PHONE E-MAIL YOUR ORGANIZATION CCSA Compass Intervention Center Comprehensive Counseling Network DCS Juvenile Court Evaluation & Referral Lakeside Memphis City Schools Midtown Mental Health Center Shelby County Schools St. Francis Shelby Training Center Southeast Community Mental Health Center St. Peter's School Tall Trees Whitehaven Community Mental Health Center Youth Habilitation Center Youth Villages Other IF NOT LISTED* * If your organization is not listed, select 'Other' and type in above

Client Profile / Case Description Referral attempt made to: Compass Intervention Center Comprehensive Counseling Network Lakeside Midtown Mental Health Center Parkwood Behavioral Center Southeast Community Mental Health Center St. Francis St. Peter's School Whitehaven Community Mental Health Center Youth Habilitation Center Youth Villages Boys Town Youth Villages Center For Intensive Residential Treatment Youth Villages Deer Valley Youth Villages Dogwood Valley Youth Villages Family Link Youth Villages Specialized Crisis Service Other If other: Referral date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1998 1999 2000 2001 2002 2003 2004 2005 At time of referral, child was in custody of: Legal Guardian Biological Parent Adoptive Parent Relative Family Friend Department Of Children's Services Youth Services Bureau At the time referral was made, child's placement was: Legal Guardian Foster Home Acute Care Lakeside Behavioral St. Francis Other If other: Residential Treatment Compass Intervention Center Parkwood Behavioral Center St. Peter's Home For Girls Youth Habilitation Center Youth Villages Other If other: YSB Residential Placement Tall Trees Shelby Training Center St. Peter's Home Youth Habilitation Center Other If other: JC Detention Center Emergency Shelter Child's judicial status (check all that apply) Unruly Dependent / Neglect Delinquent - Misdemeanors Delinquent - Felonies In YSB Residential Placement   In Hanover House Supervised Probation Unsupervised Probation Custody - Protective Client Mental / Behavioral Profile Age: Mental health providers at time of referral (check all that apply) Compass Intervention Center Comprehensive Counseling Network Lakeside Midtown Mental Health Center Parkwood Behavioral Health Shelby Training Center Southeast Community Mental Health Center   St. Francis St. Peter's School Tall Trees Whitehaven Community Mental Health Center Youth Habilitation Center Youth Villages Other: Current insurance: TennCare Private Insurance Uninsured What prompted the need for this referral? (check all that apply)   Reason(s) Explanation / Comments Treatment / services needed for the following behaviors or symptoms: (check all that apply) Suicidal Ideations Homicidal Ideations Violent / Explosive Acting-out Active Psychotic Symptoms Other: Had to be moved from current placement Other: Diagnosed mental / behavioral conditions at time of referral? (check all that apply)     Diagnosis Adjustment Disorder Alcohol Abuse Alcohol Dependence Amphetamine Abuse Amphetamine Dependence Anxiety Disorder NOS Anorexia Nervosa Asperger's Disorder Attention-Deficit Hyperactivity Disorder Autistic Disorder Bipolar Disorder Bulimia Cannabis Abuse Cannabis Dependence Cocaine Abuse Cocaine Dependence Conduct Disorder Depressive Disorder NOS Disruptive Behavior Disorder NOS Dysthymic Disorder Eating Disorder NOS Encopresis Enuresis Generalized Anxiety Disorder Learning Disorder NOS   Diagnosis Major Depressive Disorder Mental Retardation (severity unspecified) Mild Mental Retardation Moderate Mental Retardation Mood Disorder NOS Neglect of Child Oppositional-Defiant Disorder Panic Disorder Paraphilia NOS Pedophilia Pervasive Developmental Disorder NOS Physical Abuse of Child Polysubstance Dependence Posttraumatic Stress Disorder Reactive Attachment Disorder Schizoaffective Disorder Schizophrenia Schizophreniform Disorder Selective Mutism Separation Anxiety Disorder Severe Mental Retardation Sexual Abuse of Child Sexual Disorder NOS Tourette's Disorder Other:     By whom was diagnosis made: Compass Intervention Center Comprehensive Counseling Network Lakeside Midtown Mental Health Center Parkwood Behavioral Health Southeast Community Mental Health Center St. Francis St. Peter's School Whitehaven Community Mental Health Center Youth Habilitation Center Youth Villages Other   Comments: Reasons for denial or delay of service: (check all that apply)   Reason(s) Explanation / Comments No Vacancy Inadequate Insurance No Insurance Low IQ / Mental Retardation Inappropriate Referral Waiting List Past Referral Items Has a referral attempt been made and denied for this child in the past? Yes No (If answering Yes, please fill in the information below. If answering No, just submit the form.) Client Profile / Case Description At Time Of Referral Past referral attempt made to: Compass Intervention Center Comprehensive Counseling Network Lakeside Midtown Mental Health Center Parkwood Behavioral Center Southeast Community Mental Health Center St. Francis St. Peter's School Whitehaven Community Mental Health Center Youth Habilitation Center Youth Villages Boys Town Youth Villages Center For Intensive Residential Treatment Youth Villages Deer Valley Youth Villages Dogwood Valley Youth Villages Family Link Youth Villages Specialized Crisis Service Other If other: Past referral date: January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1998 1999 2000 2001 2002 2003 2004 2005 At time of this referral, child was in custody of: Legal Guardian Biological Parent Adoptive Parent Relative Family Friend Department Of Children's Services Youth Services Bureau At the time this referral was made, child's placement was: Legal Guardian Foster Home Acute Care Lakeside Behavioral St. Francis Other If other: Residential Treatment Compass Intervention Center Parkwood Behavioral Center St. Peter's Home For Girls Youth Habilitation Center Youth Villages Other If other: YSB Residential Placement Tall Trees Shelby Training Center St. Peter's Home Youth Habilitation Center Other If other: JC Detention Center Emergency Shelter Child's judicial status at time of referral (check all that apply) Unruly Dependent / Neglect Delinquent - Misdemeanors Delinquent - Felonies In YSB Residential Placement   In Hanover House Supervised Probation Unsupervised Probation Custody - Protective Client Mental / Behavioral Profile At Time Of Referral Age: Mental health providers at time of referral (check all that apply) Compass Intervention Center Comprehensive Counseling Network Lakeside Midtown Mental Health Center Parkwood Behavioral Health Shelby Training Center Southeast Community Mental Health Center   St. Francis St. Peter's School Tall Trees Whitehaven Community Mental Health Center Youth Habilitation Center Youth Villages Other: Insurance at time of referral: TennCare Private Insurance Uninsured What prompted the need for this referral? (check all that apply)   Reason(s) Explanation / Comments Treatment / services needed for the following behaviors or symptoms: (check all that apply) Suicidal Ideations Homicidal Ideations Violent / Explosive Acting-out Active Psychotic Symptoms Other: Had to be moved from current placement Other: Diagnosed mental / behavioral conditions at time of referral? (check all that apply)     Diagnosis Adjustment Disorder Alcohol Abuse Alcohol Dependence Amphetamine Abuse Amphetamine Dependence Anxiety Disorder NOS Anorexia Nervosa Asperger's Disorder Attention-Deficit Hyperactivity Disorder Autistic Disorder Bipolar Disorder Bulimia Cannabis Abuse Cannabis Dependence Cocaine Abuse Cocaine Dependence Conduct Disorder Depressive Disorder NOS Disruptive Behavior Disorder NOS Dysthymic Disorder Eating Disorder NOS Encopresis Enuresis Generalized Anxiety Disorder Learning Disorder NOS   Diagnosis Major Depressive Disorder Mental Retardation (severity unspecified) Mild Mental Retardation Moderate Mental Retardation Mood Disorder NOS Neglect of Child Oppositional-Defiant Disorder Panic Disorder Paraphilia NOS Pedophilia Pervasive Developmental Disorder NOS Physical Abuse of Child Polysubstance Dependence Posttraumatic Stress Disorder Reactive Attachment Disorder Schizoaffective Disorder Schizophrenia Schizophreniform Disorder Selective Mutism Separation Anxiety Disorder Severe Mental Retardation Sexual Abuse of Child Sexual Disorder NOS Tourette's Disorder Other:     By whom was diagnosis made: Compass Intervention Center Comprehensive Counseling Network Lakeside Midtown Mental Health Center Parkwood Behavioral Health Southeast Community Mental Health Center St. Francis St. Peter's School Whitehaven Community Mental Health Center Youth Habilitation Center Youth Villages Other   Comments: Reasons for denial or delay of service: (check all that apply)   Reason(s) Explanation / Comments No Vacancy Inadequate Insurance No Insurance Low IQ / Mental Retardation Inappropriate Referral Waiting List