Opportunity Farm for Boys & Girls Questionnaire
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REFFERAL INFORMATION

Name of Individual Referring Youth:  
Relationship to Youth:  
Address:  
Phone:  
Email:  
Best Time to Contact You:  
YOUTH INFORMATION
Gender:   Male Female
Age:  
Date Of Birth:  
DHS Custody:   Yes No
Youth Resides With :  
School Currently Attending :  
Grade:  
Special Education Services:   Yes No
Legal Involvement:   Yes No
Charges:  
Maine Care/Medicaid Insurance:  
Other Health Insurance
(please specify): 		 
Presenting Concerns (check all that apply)
Aggressive towards others
Anxiety
Criminal Behavior
Depressed
Eating Disorder
Encopresis (soiling self)
Enuresis (wetting self)
Fire Setting Behaviors
Hyperactive
Impulsive
Lying
Mental Retardation
Oppositional

Physically Abused
Problems Sleeping
Running Away
Self-Abusive
Sexually Abused
Sexually Active
School Failure
Substance Abuse
Thoughts of Homicide
Thoughts of Suicide
Victim of Emotional Abuse
Victim of Neglect
Violence in the Home
Withdrawn

Reason For Referal :  
Which of the following treatment services has the youth utilized? (Check all that apply):  
Counseling
Crisis Unit
Emergency Shelter
Family Therapy
Psychiatric Hospitalization
Psychiatrist
Residential Placement
Does the youth have a Clinical Diagnosis?:   Yes No