Mountain Youth Resources

Client Information Referral Form

You may fill out the referral form below and submit online or click here for a copy to print and mail/fax.

Tel (828) 586-8958
Fax (828) 586-0649

Mountain Youth Resources
PO Box 99
Webster, NC 28788

Fields Marked with an * are required.

Which Mountain Youth Resource Service would you like to refer to:

Case Number:

Date/Time of Request for Services:

Worker Making Referral:

Family Name:

Date of Assessment Visit(s):

Date/Time Notified DSS of Acceptance to Services:

Primary Caregiver's Name:

Age:

Phone:

Address:

City:

State:

Zip:

Race:

Sex:

Relationship to Child:

Employment Status and Income:

Assessment of Primary Caregiver:

Second Caregiver's Name:

Age:

Phone:

Address:

City:

State:

Zip:

Race:

Sex:

Relationship to Child:

Employment Status and Income:

Assessment of Second Caregiver:

Other Agency's involved:

Juvenile Justice:
DSS:
School Setting:
Current Counselor/Therapist

Contact Information and Phone No. (s) of Agency (s) Involved:

Out of home placements in the past:

Yes:
No:

Agency(s) of Record:

Safety Concerns/Issues:

1 Child's Name:

Location:

DSS SIS #:

Maltreatment Code:

DOB:

Age:

Sex:

Race

Date child taken into custody or:

Insurance Type:

Date child in placement authority of DSS:

ID:

Assessment:

2 Child's Name:

Location:

DSS SIS #:

Maltreatment Code:

DOB:

Age:

Sex:

Race

Date child taken into custody or:

Insurance Type:

Date child in placement authority of DSS:

ID:

Assessment:

3 Child's Name:

Location:

DSS SIS #:

Maltreatment Code:

DOB:

Age:

Sex:

Race

Date child taken into custody or:

Insurance Type:

Date child in placement authority of DSS:

ID:

Assessment:

4 Child's Name:

Location:

DSS SIS #:

Maltreatment Code:

DOB:

Age:

Sex:

Race

Date child taken into custody or:

Insurance Type:

Date child in placement authority of DSS:

ID:

Assessment:

Additional Information:

In addition to the above information Mountain Youth Resources (MYR) is required by the Department of Health and Human Services (DHHS) to have in our files a copy of the following:

Family Service Case Plan
Child Services Case Plan (if there is one)
Visitation Plan
Foster Care Information
Forms 5104 and 5207

The Department of Social Services (DSS) of County hereby authorizes MYR to work with, treat, and transport the above named children, that are in the legal custody of the DSS as long as those children are in the custody of this department and for as long as the family is participating in reunification services. MYR counselors and supervisors are hereby authorized to release or share information with other agencies in the performance of services.

Email Address of Referring Agent:

Name of Referring Agent: Date: