№ files_lp_3_process_9_06230
Administrative referral record documenting client information, behavioral health history, eligibility criteria, and agency approvals for specialized behavioral rehabilitation placement within DCYF services.
Document Type: Referral Form
Program: Behavior Rehabilitation Services (BRS)
Request Type: In-Home; Treatment Foster Care (TFC); Qualified Residential Treatment (QRTP)
Agency: DCYF
Sections Included: Youth and Family Strengths and Goals; Support Needs and Goals Screening; Treatment Services; Eligibility and Referral Criteria; Approval Signatures; Medication Log and Allergy Information
Client Information Fields: Name; Preferred Name; Age; Date of Birth; FamLink PID; Region; Sex Assigned at Birth; Gender; LGBTQIA+ Status; Pronouns
Placement Information: Current Placement Setting; Family Location (City); Placement History
Education Information: Current School; Grade; IEP/504 Status
Health Information: Mental Health Diagnosis; Behavioral Health Diagnosis; Physical Health; Height; Weight; Allergies; Medication Log
Legal Information: Court Report (CFE); Legal Status (Pending, Probation, Parole, Unable to Stand Trial)
Required Supporting Documents: WISe Screen; Health Records; Mental/Behavioral Records; School Records; Incident Reports; Visit Plan; OMH Report; CIPR/15-300; IDD/DDA Reports
Approval Authorities: Case Worker; Supervisor; Area Administrator; Intensive Resources Program Consultant (IRPC)
Signatures Required: Yes
Date Fields: Date of Referral; Staffing Date; WISe Screen Date; Approval Dates
Price: 8 / 10 USD
The file will be delivered to the email address provided at checkout within 12 hours.

Don’t have cryptocurrency yet?

You can still complete your purchase in a few minutes:
  1. Buy Crypto in a trusted app (Coinbase, Kraken, Cash App or any similar service).
  2. In the app, tap Send.
  3. Select network, paste our wallet address.
  4. Send the exact amount shown above.
After sending, paste your TXID (transaction ID) and your email to receive the download link. Need help? Contact support and we’ll guide you step by step.