Remembrance Ranch · 2024-2025 Remembrance Ranch Referral Form Copy

Part 1: Referral Source

The information below is specific to the person completing this form and who is referring a potential client to the Remembrance Ranch program. NOTE: If you are NOT the parent/guardian, you must have the parent/guardian complete a release of information form prior to submitting this referral. You can send the parent/guardian the following link and have them complete a Release Form: www.experiencetransformation.org You can also call the parent/guardian and simply ask them to complete this Referral form in your place. In this case, the Release of Information is not needed at this phase in the admission process.

Referral Source *

First Name

Last Name

Referral Source Category *

Please check the category in which you fall under in regards to the Teen

School

Parent/Guardian

Church

Law Enforcement

Other

Relationship to Teen *

Please indicate your relationship to referred Teen (eg. School Social Worker, Parent, Youth Group Leader, etc.)

Referral Source Email *

Verify Email *

Referral Source Phone Number *

Referral Source Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Part 2: Teenager Identification

Name of Teenager being referred *

First Name

Last Name

Current Grade *

Gender *

Current Age *

Birthday *

(mm/dd/yyyy)

School *

Please indicate the school that the Teen currently attends

Part 3: Parent/Guardian Identification

If the parent/guardian is not the referring source, please complete the information below.

Name of Parent/Guardian (1)

First Name

Last Name

Name of Parent/Guardian (2)

First Name

Last Name

Phone

Email

Verify Email

Parent/Guardian Address *

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Referral Questions - Scale A

All ratings should be based on your observations of this youth's behavior DURING THE PAST 3 MONTHS. The rating points after each item are based on the following format: NEVER: If the youth does not exhibit a particular behavior, or if you have not had the opportunity to observe a particular behavior, mark 1, which indicates Never. FREQUENTLY: If the youth often exhibits a particular behavior, mark 5, which indicates Frequently. SOMETIMES: Mark the numbers 2, 3, 4 (which indicates Sometimes), if the youth exhibits behavior somewhere in between the two extreme rating points, based on your judgement of how frequently it occurs. Note: We need the referring person to be completely honest in completing the questions below as we use this to determine GREATEST NEED.

Cooperates with other students at school *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Makes appropriate transitions between activities at school *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Listens to and carries out directions from teachers *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Cooperates with peers during activities outside school *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Remains calm when problems arise at home *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Completes school assignments or other tasks independently *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Makes appropriate transitions between activities at home *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Remains calm when problems arise at school *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Behaves appropriately at home *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Completes school assignments on time *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Responds appropriately when corrected by an adult *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Follows school and classroom rules *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Controls temper when angry at home *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Shows self control at school *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Behaves appropriately at school *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Responds appropriately when corrected by teachers *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Follows rules at home *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Controls temper when angry at school *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Is invited by peers to join activities *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Shows self control at home *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Referral Questions - Scale B

All ratings should be based on your observations of this youth's behavior DURING THE PAST 3 MONTHS. The rating points after each item are based on the following format: NEVER: If the youth does not exhibit a particular behavior, or if you have not had the opportunity to observe a particular behavior, mark 1, which indicates Never. FREQUENTLY: If the youth often exhibits a particular behavior, mark 5, which indicates Frequently. SOMETIMES: Mark the numbers 2, 3, 4 (which indicates Sometimes), if the youth exhibits behavior somewhere in between the two extreme rating points, based on your judgement of how frequently it occurs.

Blames others for their problems *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Cheats on school work or in games *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Is dishonest, tells lies *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Is disrespectful or "sassy" *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Acts as if they are better than others *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Has temper outbursts or tantrums *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Threatens other students, is verbally aggressive *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Is physically aggressive *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Is difficult to control *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Acts impulsively without thinking *

1 - Never

2

3 - Sometimes

4

5 - Frequently

Referral Questions - Scale C

This next set of questions helps us determine greatest need by assessing negative social indicators, such as Adverse Childhood Experiences (ACEs). ACEs are traumatic events like abuse, neglect, family dysfunction, or the death of an immediate family member. All ratings should be based on your knowledge of this youth and family.

The Youth has Experienced Emotional (or Verbal) Abuse *

1 - True

2 - False

The Youth has Experienced Parental Separation or Divorce *

1 - True

2 - False

The Youth has Experienced Substance Abuse by a Household Member *

1 - True

2 - False

The Youth has Experienced Physical Abuse *

1 - True

2 - False

The Youth has Witnessed Domestic Violence *

1 - True

2 - False

The Youth Has Lived in a Household where a Family Member has a Mental Illness *

1 - True

2 - False

The Youth has Experienced Sexual Abuse *

1 - True

2 - False

The Youth Has an Incarcerated Household Member *

1 - True

2 - False

The Youth has Experienced Neglect *

1 - True

2 - False

Referral Questions - Scale D

What is the families approximate total household annual income? *

1 - Less than $20,000

2 - $20,000 - $29,999

3 - $30,000 - $49,999

4 - $50,000 - $79,999

5 - $80,000 and over

What is the parental involvement for the Youth? *

1 - Biological parents are not involved

2 - One biological parent is involved

3 - Adoptive/Foster/Mentor involved

4 - Living with one biological parent and other biological parent is involved

5 - Living with both biological parents and they are both involved

In the past 3 months, how many times has the Youth been involved in self-harm (ex. physical (cutting), verbal (talking bad about self, threatening suicide)) *

1 - 5+ times

2 - 4 times

3 - 3 times

4 - 1-2 times

5 - Never

How much involvement per year does the Youth have in extracurricular activities? ex. sport team, band, choir, robotics, clubs of any kind, youth group, boy/girl scouts, etc. *

1 - No involvement in activities

2 - 1 activity per year

3 - 2 activities per year

4 - 3 activities per year

5 - 4+ activities per year

Is there anything else we should consider about this Youth?

Any Food Allergies?