Referrals to Adriel

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

Heather Martin, Admissions Coordinator
Direct Office Phone: (937) 465-0010 ext. 147
Fax: (937) 465-2410
Email: referrals@adriel.org

 or fill out our online referral form below:


Female: 1
Male: 0

Potential openings:

Eastview --2 in May, 2 in June, 1 in July; Sycamore--1 in May, 2 in June; Detroit Street--4 in June; Maple Ridge--1 current, 1 in June/July

Detailed Residential Openings List (pdf)

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: