Referrals to Adriel

Referrals to Adriel

24 HOUR REFERRAL SERVICE: 1-800-262-0065

Adriel Admissions Coordinator
Direct Office Phone: (937) 465-0010 ext. 147
Fax: (937) 465-8690
Email: referrals@adriel.org

or fill out our online referral form below:

Female: 4
Male: 3

Current openings:

Eastview --1 current, 1 projected; Westview--2 current; Sycamore--0 current; Detroit Street--3 current; Maple Ridge--1 current

Read detailed information about

the group homes

Foster Care Capacity: 180+ Children
(male, female, sibling groups)

Program Requested :

Referring Agency:

Contact Person:

Phone:

Email:

Youth:

Date Placement Needed:

DOB:

Age:

Gender:

Race:

Current Placement:

Reason for Disruption:

Placement History:

Current Issue	History	Presenting Problem	Current Issue	History	Presenting Problem
		Abused - Physical			Psychotic
		Abused - Sexual			Suicidal / Homicidal
		Alcohol and/or Drug Use			Stealing
		AWOL			Self-Destructive
		Cruelty to Animals			Self-Mutilation
		Fire Setting			Sexually Active
		Hallucinations			Sexualized Behaviors
		Lying / Manipulative			Sexual Offender (Adjudicated)
		Neglected			Verbally Aggressive
		Physical Aggression			Other

Education
Current Grade Level: >>>>School Behaviors:

Regular Classes ED IEP LD IEP DH IEP

Performance IQ:     Verbal IQ:     Full Scale IQ:

Custody Status (check one and fill in appropriate blanks)
Parent / guardian:

Temporary Care Agreement with Parent Guardian for County

County has:
Ex Parte
TC
PC
PPLA

Discharge Plan:

Expected Length of Stay:

Visitation: with whom, location, frequency, supervised (if yes by whom)

Juvenile Court Involvement:
On Probation: Yes No For:

Medical Needs:

Diagnosis:

Medication:

Currently in Mental Health Treatment: Yes No Where:

Currently in Alcohol or Drug Treatment: Yes No Where: