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Residential Services Application
APPLICATION FOR RESIDENTIAL SERVICES
Youth's legal Name:
First name
Middle Name
Last Name
Gender at birth:
M
F
Birthdate:
Social Security Number
Address:
City, State, Zip
Country of Residence:
Youth's Race:
Black/African American Native
White/Caucasian
Multiple Race
Asian
Alaskan
Native American
Native Hawaiian/Other Pacific Islander
Other
Youth's Ethnicity
Puerto Rican
Mexican
Cuban
Other Hispanic
Not Hispanic or Latino
Legal Guardian's Name:
Address:
City, State, Zip:
Phone No.:
May we leave a message?
Yes
No
Email Address:
In case of emergency or illness renders the youth incapable of exercising treatment choices, we will contact Westwood Behavioral Health Crisis Intervention Services or Coleman Professional Services (after hours and weekends), or Van Wert County Hospital unless otherwise indicated below.
As the youth or Authorized Representative/Legal Guardian, I prefer The Marsh Foundation contact the following in case of emergency or illness during treatment:
Name:
Relationship to youth:
Emergency Contact Phone No.:
Address:
Who is responsible for payment of placement?
Funding Source
Parent
IV-E
Cluster
Other, explain:
Permanency Plan
Reunification
Adoption
Relative Placement
Emancipation/Ind. Living
PPLA
Other
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Foster Parenting FAQ
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