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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.
    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 Recently discharged from hospital
    Yes Yes Multiple mobile crisis or psychiatric ER visit/hospitalization
    Yes Yes Has a pattern of hospitalization or
    is at high risk of being hospitalized due to MH symptoms, behaviors, or undiagnosed or unmedicated MH concerns
    Yes Yes Past history of treatment without much improvement within the last six months
    Yes Yes Is at risk of IP/PHP or other residential settings
    Yes Yes Has a Mental Health diagnosis
    Yes Yes Does young person have an
    active/ongoing psychosis, or active suicidality or homicidality?
    Yes Yes Other