SailFuture: Child Residential Referral

Thank you for your interest in referring a child to the SailFuture residential program.

To assist us in evaluating the suitability of the child you're referring, please fill out the form below with as much detail as possible.

The accuracy of your submission will be crucial in determining our ability to serve the placement needs of your referral.

Thank you for your interest in referring a child to the SailFuture residential program.

To assist us in evaluating the suitability of the child you're referring, please fill out the form below with as much detail as possible.

The accuracy of your submission will be crucial in determining our ability to serve the placement needs of your referral.

Child Name *

Child Birthday *

Gender *

Home Circuit *

Case Manager Name *

Case Manager Email *

CMO Name *

Case Manager Phone Number *

How long has the child been in the system of care? Estimated number of placements? *

What are the child’s typical behaviors and triggers? *

What do the family relationships and support systems look like for the child? *

What is the child’s current educational status, grade, and level of engagement? *

Are individual or family counseling services in place? If so, what is the current level of engagement? *

Are there concerns of substance abuse? If so, which substances and how frequently? *

Medications? dosage? is youth compliant? Last medication management appointment? *

Does the student have any special medical needs? *

Does the student have any information regarding the SailFuture program? If so, what is their level of interest? Are they comfortable with international travel and water-based experiences? *

Does the student have a safety plan or other restrictive placement agreements? *

CBHA *

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Additional CBHA information or important notes

DJJ FaceSheet

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Additional DJJ information or important notes

Comprehensive Placement Assessment

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CPA Notes