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Shine Your Light 5K
Screening Form - ShineLight
Managed Care Organization (MCO)
Name of Child/Adolescent
Date of Birth
Social Security Number
a) Natural Support System:
b) Income Range:
$10,000 - $30,000
$30,000 - $50,000
$50,000 - $80,000
$80,000 - $100,000
d) Birthday of Natural Support System
e) Highest Level of Education
Please choose one
High School Diploma
Local Community Groups
a) Insurance Carrier:
b) Name Person Responsible for Co-Pay:
Does your child have any allergies?
1. How did you learn about Shine-Light, Inc.?
2. Reason(s) for requesting services
3. Is the child/adolescent currently placed outside their home?
Where is the placement and when did it occur?
4. What is your child's current health status?
a) Axis I:
b) Axis II:
c) Axis III:
6. Treatment Level
7. What effect has the child/adolescent's problems had on the following settings?
8. Tell me about your child in the following areas:
9. Describe team involvement:
10. What does your child and family identify as the most important goal/need at the present time? (Short-Term Goals)
11. From your perspective, please describe what you think are the child/adolescent's and family's goals/needs. (Long-Term Goals)
12. What are your expectations of Shine-Light, Inc.?
13. Are you available for home visits during holidays?
14. Will the parent/guardian be available for doctor's visits?