Admissions & Placement Referral Form — Texas Tranquility Estates, Inc.

Section 1 — Referring Agency / Caseworker Information

Agency / Organization Name

Caseworker / Referral Contact Name

Title / Position

Phone Number

Fax Number

Email Address

Mailing Address

City, State, ZIP

Date of Referral

Case / File Number

Section 2 — Youth Information

Youth's Full Legal Name

Preferred Name / Nickname

Date of Birth

Age

Gender Identity

Race / Ethnicity

Primary Language

Secondary Language (if any)

Current Address / Placement Location

City, State, ZIP

Section 3 — Legal & Custody Status

Legal Status

Foster Care (DFPS) Voluntary Placement Juvenile Justice Private Pay Other

Managing Conservatorship Held By

Court / Jurisdiction

Next Court Date

DFPS Region / Unit (if applicable)

Placement Authorization Number

Section 4 — Parent / Guardian Information

Parent / Guardian Name

Relationship to Youth

Phone Number

Email Address

Address

Parental Rights Status

Intact Restricted Terminated Unknown

Section 5 — Education

Current School / District

Current Grade Level

IEP / 504 Plan in Place?

Yes — IEP Yes — 504 No Unknown

Special Education Services Needed

Academic Strengths

Academic Challenges

Section 6 — Medical & Mental Health

Primary Care Physician

Health Insurance / Medicaid ID

Current Medications

Prescribing Physician

Known Allergies

Chronic Medical Conditions

Diagnosed Mental Health Conditions (check all that apply)

Other Mental Health Diagnoses

Current Therapist / Counselor

Therapy Frequency

History of Psychiatric Hospitalization?

Yes No

If Yes, Most Recent Date & Facility

Section 7 — Behavioral & Safety History

Additional Behavioral Notes / Safety Concerns

Section 8 — Placement History

Number of Prior Placements

Reason for Current Referral / Placement Need

Summary of Prior Placement History

Section 9 — Goals & Strengths

Youth's Identified Strengths & Interests

Short-Term Goals for This Placement

Section 10 — Authorization & Signature

By submitting this form, I certify that the information provided is accurate and complete to the best of my knowledge, and that I am authorized to submit this referral on behalf of the youth and/or referring agency.

Authorized By (Printed Name)

Date

Title / Position

I understand that submitting this form electronically constitutes my authorization and consent.