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Functional Family Therapy (FFT) Referral

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    Referrer Information






    Youth and Family Demographics:



















    Yes


    FFT Priority Criteria Checklist

    Past 3 Months Past Year Criteria Briefly provide additional information regarding youth’s CURRENT EXTERNALIZING behaviors that put him/her at risk for out-of-home placement.
    Yes Yes At risk of out-of-home placement
    Yes Yes Physical Aggression
    Yes Yes Substance Abuse/Use
    Yes Yes Negative Peer Associations
    Yes Yes Theft
    Yes Yes Verbal Aggression
    Yes Yes Property Destruction/Vandalism
    Yes Yes Runaway
    Yes Yes Truancy
    Yes Yes School Failure/Suspensions
    Yes Yes Family Conflict/Discord
    Yes Yes Mental Health
    Yes Yes Other