If you have Medicaid, do not complete this form; instead, complete this form.”

Disclaimer: Parent/Legal Guardian should be aware of any inquiry made for an IACCT.


If there is an immediate safety risk please call 911

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* 1. Today's Date

Date

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* 2. Name and contact info for the person making Inquiry

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* 3. Alternate Contact

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* 4. Relationship to Youth

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* 5. Youth's Name

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* 6. Youth's Date of Birth

Date

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* 7. Youth's street address

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* 8. Name of Legal Guardian (s)

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* 9. Phone Number of Legal Guardian (s)

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* 10. Legal Guardian's Locality (City or County)

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* 11. Does the legal guardian need interpreter services?

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* 12. Is the youth in foster care?

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* 13. Is the youth involved with their local Family Assessment and Planning Team (FAPT)

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* 14. Briefly, what is the reason for this Inquiry?

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* 15. What other services or treatment prior to this Inquiry has been attempted?

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* 16. Is the youth currently in psychiatric or substance use inpatient facility?

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* 17. Where does the youth currently reside?

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