Courts/Organization/Inpatient Facility Application
Client's Name:
Date of Phase Intake:
Intake Worker:
Client Social Security#:
Date of Birth:
Male/Female:
Substances Used:
  Age 
Race

 Has client had previous counseling for substance abuse or mental health issues?
Referral Agency/Persons Role
Client Lives With Whom


Counselor's Name: 

In School? Yes/No:
Name Of School:
Highest Grade Completed:



Referring Counselor/Probation Officer

Mailing Address

Phone Number

Comments
 
Parent or Guardian Name:
Client Address:
Phone:
Email:

 

Reason For Referral:
Screening Mode: Face To Face
Telephone
Written
N/A
Address:
Yes No
Current Date Pending?:
If Yes relate:
Court Ordered?:
Employed:
 
DJJ:
Is supervision formal or informal
If informal date ends:


Medical Insurance
Yes/No:
Insurance #:
Company Name:


Comments
Disposition: Defer Admit
 
Date
TRY Counselor


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 Treatment Resources for Youth, Inc.
2517 North Charles Street
Baltimore, Maryland 21218

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