ADNJ Youth & Family Services Client Screening / Referral Form Please complete all required fields marked with an asterisk (*) Client InformationClient Name *Date of Birth *Referent Name *Referent Email *Referring Agency *Referring Agency Address *Referring Agency City, State and Zip Code *Referring Agency Telephone Number *Legal Guardian Name *Legal Guardian Address *Legal Guardian City, State and Zip Code *Legal Guardian Telephone Number *Presenting Problems / SituationsHistory of depression?YesNoHistory of running away?YesNoHistory of anxiety disorder?YesNoHistory of obsessive/compulsive disorder?YesNoHistory of conduct disorder?YesNoHistory of oppositional defiant disorder?YesNoHistory of substance/alcohol use/abuse?YesNoHistory of school truancy?YesNoHistory of academic performance?YesNoHistory of anger/aggression?YesNoHistory of at-risk behaviors to self and others?YesNoCurrent GradeCurrent SchoolIEPYesNoClient's current known diagnosesClient's current and/or past medical problemsSupervised ProbationSupervised ProbationYesNoUnknownProbation Officer NameProbation Officer Telephone No.DistrictCurrent MedicationsName of MedicationDosageDiagnosisAdditional DetailsOnset and duration of problemList the individual's Psychiatric needsList the individual's Support needsAction TakenIndividual is acceptedIndividual is not acceptedReason not acceptedStaff Use OnlyStaff Signature/TitleDateSubmit Client InformationClient Name *Date of Birth *Referent Name *Referent Email *Referring Agency *Referring Agency Address *Referring Agency City, State and Zip Code *Referring Agency Telephone Number *Legal Guardian Name *Legal Guardian Address *Legal Guardian City, State and Zip Code *Legal Guardian Telephone Number *Presenting Problems / SituationsHistory of depression?YesNoHistory of running away?YesNoHistory of anxiety disorder?YesNoHistory of obsessive/compulsive disorder?YesNoHistory of conduct disorder?YesNoHistory of oppositional defiant disorder?YesNoHistory of substance/alcohol use/abuse?YesNoHistory of school truancy?YesNoHistory of academic performance?YesNoHistory of anger/aggression?YesNoHistory of at-risk behaviors to self and others?YesNoCurrent GradeCurrent SchoolIEPYesNoClient's current known diagnosesClient's current and/or past medical problemsSupervised ProbationSupervised ProbationYesNoUnknownProbation Officer NameProbation Officer Telephone No.DistrictCurrent MedicationsName of MedicationDosageDiagnosisAdditional DetailsOnset and duration of problemList the individual's Psychiatric needsList the individual's Support needsAction TakenIndividual is acceptedIndividual is not acceptedReason not acceptedStaff Use OnlyStaff Signature/TitleDateSubmit
