Presbyterian Homes & Family Services - Programs & Admissions

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Childrens Referral 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.
Campus Of Interest:
Child's Date of Birth:
Placement Services Requested:
Placement Date (anticipated):
Length of Placement (projected):

Please answer or provide information that will answer each of the following: All Fields Required
Why are you requesting out of home services?
What specific physical needs does this child present?
What educational needs does this child have?
What mental health, emotional and/or psychological needs does this child present?
What health care needs does this child require?
What protection/supervision needs this child require?
Why do you feel this facility is suitable for this child?
Does the admission of this child present any significant risk to him/her?
Does the admission of this child present any risk to other residents or staff?
What are the short & long term discharge plans for this child?

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.
Your Name:
Date:
Street Address:
City:
State:	Zip:
Organization or Agency:
Your Phone Number:

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