Please fill this out to the best of your ability. If there is anything you do not know the answer to, please leave it BLANK.
Who is entering this data?
Client (Youth) Information
What living situation does the ZIP code above indicate?
What is the client's sex assigned at birth?
What is the client's race/ethnicity? (Please choose to the best of your ability.)
Does the client have IDD?
What is the IDD diagnosis?
Is the client crossover (Juvenile Justice to Dependency & Neglect)?
What insurance does the client have?
Is the client pre-adjudicated or on probation? (Leave blank if neither)
What date was the client referred to us?
What type of meeting is this?
In which program are we serving the client (for this instance)?
When did the final meeting take place? In other words, the meeting when the plan was finalized.
What is the date of entry into the detention facility? (Leave blank if not applicable)
Was an integrated multi-agency service plan developed?
Did the court approve this plan? (Leave blank if not applicable or if answer is not yet known. When it is known, contact Shelby directly to provide update)
Was a 2Generation model used? In other words, were both the caregiver and youth involved in planning?
Were blended/braided funds used?
Who attended the meeting? (Check all that apply).
If a meeting attendee wears multiple "hats" (for example, representing an organization that provides mental health and substance abuse services), mark all of their "hats."
What agencies/providers/systems have a role in delivering services from this plan? (Check all that apply)
If a meeting attendee wears multiple "hats" (for example, representing an organization that provides mental health and substance use services), mark only the options indicating what service they are delivering. This may be more than one.