You’re offline. This is a read only version of the page.
Skip to main content
Reporter Portal
Toggle navigation
Home
Support
Back Home
New Report
Individual Applications Public Questionnaire
Person Details
Documents Upload
Review
Eligibility Questions
Getting Started
Select if you are applying on behalf of a child
Individual Applications Public Questionnaire
Record Type
Clear lookup field
Launch lookup modal
Lookup records
×
Close
We're sorry, an error has occurred.
There are no records to display.
You don't have permissions to view these records.
Error completing request.
Loading...
Error
×
Close
We're sorry, an error has occurred.
Is the child a U.S. Citizen?
Is the child a U.S. Citizen?
No
Is the child a U.S. Citizen?
Yes
Is the child a qualified alien?
Is the child a qualified alien?
No
Is the child a qualified alien?
Yes
Is the child under the public custody of a Human Service Zone, Division of Juvenile Services or a North Dakota Tribe?
Is the child under the public custody of a Human Service Zone, Division of Juvenile Services or a North Dakota Tribe?
No
Is the child under the public custody of a Human Service Zone, Division of Juvenile Services or a North Dakota Tribe?
Yes
Is the youth under the custody of the Division of Juvenile Services (DJS), living with parents or a relative receiving services in the community; meaning you are referring a youth under the custody of a public agency, however he/she is not in a foster care placement.
Is the youth under the custody of the Division of Juvenile Services (DJS), living with parents or a relative receiving services in the community; meaning you are referring a youth under the custody of a public agency, however he/she is not in a foster care placement.
No
Is the youth under the custody of the Division of Juvenile Services (DJS), living with parents or a relative receiving services in the community; meaning you are referring a youth under the custody of a public agency, however he/she is not in a foster care placement.
Yes
Is the individual you are referring, a child under the age of 18 years old? (Prenatal referrals are not eligible until after the birth of the child.)
Is the individual you are referring, a child under the age of 18 years old? (Prenatal referrals are not eligible until after the birth of the child.)
No
Is the individual you are referring, a child under the age of 18 years old? (Prenatal referrals are not eligible until after the birth of the child.)
Yes
Does the child, under age 18, meet at least one of these characteristics that without supportive service or preventative care, out of home placement is likely. Check all that apply:
DSM Diagnosis for an emotional, behavioral, or mental health disorder with symptoms are expected to last or have lasted one year or longer.
Child has a serious emotional disturbance.
Bipolar I Disorder
Autism Spectrum Disorder
Attention-Deficit/Hyperactivity Disorder
Major Depressive Disorder, Single and Recurrent Episodes
Disruptive Mood Dysregulation Disorder
Separation Anxiety Disorder
Specific Phobia
Social Anxiety Disorder (Social Phobia)
Generalized Anxiety Disorder
Obsessive-Compulsive Disorder
Posttraumatic Stress Disorder
Anorexia Nervosa
Oppositional Defiant Disorder
Intermittent Explosive Disorder
Conduct Disorder
Other
DSM Diagnosis Other
*
Child has moderate to severe impairment or limitations in the home, school, or community.
Child has moderate to severe impairment or limitations in their achievement of a developmentally appropriate skill (social, behavioral, cognitive, communicative, or adaptive).
Child has been adopted and the current arrangement is at risk of a disruption.
Child entered a legal guardianship and the arrangement is at risk of a disruption.
Child/youth is pregnant or parenting a child(ren).
Child has siblings currently placed in foster care.
Child is actively involved with in-home case management through a local human service zone or tribal social office.
Child is actively involved with child protective services through a local human service zone or tribal social service office.
Child is actively involved with the Division of Juvenile Services.
The child has experienced a prior out of home placement.
Child is currently involved in two or more services offered in the community by a local agency.
The child was previously in foster care.
The child has experienced inadequate supervision in the home based on family and youth circumstances.
The child is cared for by an adult in the home (Parent/Custodian/Guardian/Kin Caregiver) who has limited parental capacity to meet educational, medical, safety, or basic needs of the child(ren) due to the adult’s: check all that apply
Mental health or substance use concerns
Inability to address serious needs of the child
Physical or intellectual disability
Debilitating or life-threatening medical needs
Homelessness or substandard living conditions
No longer able to maintain the child’s behavioral
Prenatal exposure of substances resulting in the birth of a substance exposed newborn
Incarceration (at least one parent)
REQUIRED: Please explain in detail on how the characteristics/circumstances checked in eligibility questions put the child at risk of out of home placement:
*
*
