Are You Ready to Work With Us? | Greenfield Child and Youth Services

Section 1

Referral & Service Request

Date of Referral

Desired Start Date of Service

Referring Worker Name & Title

Email

Phone Number

Referring Agency

Address Where Service is Required (if applicable)

After-Hours Emergency Contact

Type of Service Requested

One-to-One Support in CommunityOne-to-One Support in Client's ResidenceEmergency Bed PlacementRespiteSupervised Visits

Service Urgency

Immediate / CrisisWithin 24–72 HoursWithin 1 WeekFlexible / Waitlist Acceptable

Describe the requested service(s)

Describe Greenfield CYS's role in the intervention

Success indicators / goals of service

Documentation expectations

Any restrictions or limitations

Any known placement conflicts or concerns

Anything else critical Greenfield CYS should know

Section 2

Client Information

Client Full Name

Preferred Name

Pronouns

Date of Birth

Primary Language

Interpreter Required

Yes No

Address for Service

Current Living Situation

If Other, please specify

Legal Guardian / Caregiver Name(s)

Who has decision-making authority?

Consent for service obtained

Yes No

Section 3

Daily Routine & Education

Client's daily schedule / routine

Current school / program

Grade

Attendance concerns

Yes No

Appointments client must attend

Is worker expected to accompany client?

Yes No

Section 4

Safety, Supervision & Mental Health

Section 5

Clinical & Developmental Information

Section 6

Cultural & Service Logistics

Section 7

Signatures & Additional Information

Referring Worker Signature (type full name)

Guardian / Caregiver Signature (if applicable)

Date Signed

How did you hear about us?

Greenfield CYS Intake Reviewed By (office use)

Intake Approval Date (office use)

Additional Information / Comments