"Mental Health and Substance Abuse Screening Report and Referral Form" - Florida

Mental Health and Substance Abuse Screening Report and Referral Form is a legal document that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida.

Form Details:

  • The latest edition currently provided by the Florida Department of Juvenile Justice;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download "Mental Health and Substance Abuse Screening Report and Referral Form" - Florida

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MENTAL HEALTH AND SUBSTANCE ABUSE
SCREENING REPORT AND REFERRAL
(Offline version no JJIS available)
REPORT DATE: _____/____/_______
YOUTH: ______________________________DJJID : ___________ DOB: ___/___/____ AGE: _____
CHARGES:
REFERRAL #
CATEGORY/DEGREE
FLORIDA STATUE
OFFENSE
Yes
No
A. Immediate referral for mental health service is indicate d by the Suicide Risk Instrument.
Yes
No
B. No PACT information available at this time. Screener decision for further testing.
NARRATIVE FOR SCREENER DECISION:
C. Referred for Services to: _____________________________________________________________________
D. Placement following screening:
Detained
Released to parent/ guardian (includes home detention)
Other _______________________________________________________
My signature below confirms that I have been notified of the above screening results.
_______________________________________ _________________________ ________________
Signature of person taking custody of youth
Relationship to youth
Date of release
CC:
TASC
Parent/ Guardian
Other _________________________
Reset/Clear Form
Print Form
Save As
MENTAL HEALTH AND SUBSTANCE ABUSE
SCREENING REPORT AND REFERRAL
(Offline version no JJIS available)
REPORT DATE: _____/____/_______
YOUTH: ______________________________DJJID : ___________ DOB: ___/___/____ AGE: _____
CHARGES:
REFERRAL #
CATEGORY/DEGREE
FLORIDA STATUE
OFFENSE
Yes
No
A. Immediate referral for mental health service is indicate d by the Suicide Risk Instrument.
Yes
No
B. No PACT information available at this time. Screener decision for further testing.
NARRATIVE FOR SCREENER DECISION:
C. Referred for Services to: _____________________________________________________________________
D. Placement following screening:
Detained
Released to parent/ guardian (includes home detention)
Other _______________________________________________________
My signature below confirms that I have been notified of the above screening results.
_______________________________________ _________________________ ________________
Signature of person taking custody of youth
Relationship to youth
Date of release
CC:
TASC
Parent/ Guardian
Other _________________________
Reset/Clear Form
Print Form
Save As