REFERRAL FORM

Demographic Information

Date:

Client Name:

D.O.B.:

Gender:
---MaleFemale

Ethnicity:
---African AmericanCaucasianHispanicOther

Address:

City:

State:

Zip Code:

Home Phone:

Cell Phone:

Work Phone:

Email Address:

OK to leave messages? (Check all that apply)

HomeCellText MsgEmailAll

School:

Grade:

Referred by:

DJO Contact Number:

Parent Information

Parent/Legal Guardian Name:

Relationship:

Parent/Legal Guardian Name:

Relationship:

PLEASE NOTE: Only those who are legally authorized to make decisions about medical treatment for this minor child may consent to services.

Description of Current Problem (Check all that apply)

Anger ManagementAnxietyAbuse/ViolenceSleeping ProblemsDepressionInattentivenessSelf EsteemChronic Pain/IllnessHyperactiveTraumaBullyingPower/Control ChallengesFamily ConcernsWithdrawnEating DisorderPeer Issues/Social SkillsSubstance AbuseGrief/LossAttachment IssuesSibling RivalrySchool-Related IssuesAdoption/Foster-care Adjustment IssuesCrisis InterventionRelationship Concerns

Medications:

Diagnosis:

Additional information (Please include strategies used at home/or at school):

ST. VINCENT HOME TEMPORARY SHELTER PLACEMENT AGREEMENT
TEMPORARY INFORMED CONSENT FOR TREATMENT

I affirm that I have been informed of the Temporary Shelter Program treatment and services. I agree that St. Vincent Home for Children, its members, and agents have my full and free consent to perform such services as are deemed appropriate by the Home’s clinical staff in treatment of , and that there are no known side effects to residential treatment. I understand that I retain full legal custody of my child, and as his/her parent/legal guardian, I am expected to be involved and engaged throughout the duration of the program.

I understand and agree to these components of the Temporary Shelter Program:

• Child will participate in weekly therapy sessions and scheduled group activities.
• Parent(s) will participate in weekly in-home therapy sessions.
• Child will remain in the shelter for the first weekend. He/she may go home for a weekend visit each subsequent weekend.
• After a maximum of thirty (30) days in the shelter, child and family will participate in weekly in-home therapy for an additional ninety (90) days

St. Vincent Home for Children does not use any non-traditional, unconventional or controversial treatment modalities or activities. However, when other methods have failed to resolve a crisis, I understand and have been informed that the Home reserves the right to use physical intervention and/or locked isolation in specific situations such as:

1. To prevent a child from injuring himself/herself
2. To prevent a child from injuring another child or others

I have been informed that St. Vincent Home for Children reserves the right to conduct searches for contraband. I have been informed that St. Vincent Home for Children conducts drug testing on all children at admission or as needed. I understand that St. Vincent may seek emergency medical care for my child when there is an immediate medical need for assistance and there may be costs associated with such care. This consent remains valid through the final discharge date of the child.

YesNo - I understand that the Temporary Shelter Program is funded through St. Louis County Children’s Service Fund at no cost to me. I understand that representatives of Children’s Service Fund can review my child’s file for compliance to Children’s Service Fund guidelines.

YesNo - I understand that I MUST come to St. Vincent Home for Children to complete the entire admission process for continued enrollment in the program.

YesNo - I understand that if I do not come to St. Vincent Home for Children to complete the entire application by 4:00 p.m. the next business day a hotline call may be placed to Missouri Children’s Division for abandonment.

In submitting this form, I am agreeing to transportation to and placement of in St. Vincent Home for Children’s Temporary Shelter Program. I understand that all services received while in the program and the after-care services will be provided at no cost to me. I understand a preliminary chart will be open on my child’s behalf.

Relationship to Child:

Important Parent/Guardian Information

You have admitted your child for a thirty (30) day intensive therapeutic residential program at Saint Vincent Home for Children.  The program is structured and ruled and works most efficiently with you also complying with those rules. 

After admission, you are free to contact us to visit or leave the premises with your child with prior notice.  The only requirement is that the child NOT leave the facility for the first full weekend of their stay.  This allows the child to become acclimated to their new surroundings and to realize their actual purpose in the program. 

If you plan to visit on-campus, visiting hours are as such: 

• Monday through Saturday, visiting hours are from 8:00 AM—8:00 PM. 
• Sunday, visiting hours are from 8:00 AM—7:00 PM.

Phone calls for the residents are completed during specific time frames.  Residents are able to make phone calls every day of the week.  Monday through Friday, residents are allowed to call between the hours of 5:00 PM—8:00 PM.   

Saturday and Sunday, clients are allowed 1 five-minute phone call per shift, and there are 2 shifts.  The specific times to call are left to the discretion of the shift supervisors.  Residents are not allowed to make or receive phone calls throughout the regular business day, as they are participating in either school, groups, or activities.  If you need to speak with your child during these times, you can call the front desk and will be transferred to the resident’s assigned therapist, who can authorize a call when they are available. 

The main number to contact St. Vincent Home for Children is: 314-261-6011.  This number is active from 9:00—5:00PM Monday through Friday. If calling after 5:00 PM or during weekend hours, the number is 314-791-1460.  This number rings directly to the shift supervisor, who can assist you. 

If you desire to bring your child additional clothing, we ask that they are limited to 10 outfits total, as they are able to wash twice per week.  We may ask that you swap out clothing if we begin to accumulate excess clothing for your child. 

Lastly, your child will be assigned a therapist to work with individually and also with your family.  This assignment typically occurs within the first 3 days of their admittance.  If your therapist has not contacted you within 7 days of admittance to introduce themselves and discuss the start of family counseling, please contact us to inquire at the main number. 

Several factors determined the implementation of a No Outside Food Policy at St. Vincent Home for Children. Residents are no longer allowed to have outside food on the campus and parents are no longer allowed to provide outside food.  If food is provided for a family visit, all food must be consumed during the visit and any leftovers must be taken off site with families.  Residents are able to purchase drinks from on-site vending machines.  Residents and families who violate this rule will be required immediately to dispose of snacks and foods at that time.