The Local Care Team

Child's Name *

Date of Birth *

Gender
malefemaletransgender

Race
HispanicWhiteBlack or African AmericanAmerican Indian or Alaska NativeAsian IndianChineseFilipinoJapaneseKoreanVietnameseNative HawaiianGuamanian or ChamorroSamoan

Other Race

Address *

City ,State, Zip *
Baltimore, MD 21215212092121021212212392123421214212062121821211212162121721213212052122421231212022122321229212012123021227212252122621222

Phone Number *

Who is requesting the LCT meeting? *
Self (ages 18-21)Parent/GuardianAgencyOther

If other, please explain:

Please provide contact information, including phone number. *

What is your relationship with this individual? *

If you are not the parent or individual, do you have parental permission to discuss this information? *
YesNo

Please list any other individuals whom you would like to invite along with their contact information:

Does your child receive Medical Assistance? *
YesNo

Is your child covered by private insurance? *
YesNo

Does your child receive SSI? *
YesNo

Current School or Last School *

Please list any medical conditions:
 Anemia-(low iron) Asthma Allergy Birth Defects Bleeding problems Cerebral Palsy Diabetes Ear Infections Food Allergy Genetic Disorder Head Aches Head Injuries Hearing Problems High Cholesterol High Blood Pressure Immune Disorder Kidney Disorder Lead Poisoning Seizures Speech Disorder Sexual Transmitted Disorder (STD) Thyroid Disorder Vision Problems

Other

Please list any behavioral concerns:
 Argues or is verbally disrespectful Doesn't participate in activities that were previously enjoyable Gets into physical fights with peers or family members Steals or lies Is aggressive toward adults Has participated in self-harm (e.g. cutting or scratching self, attempted suicide) Appears sad or unhappy Has a negative or distrustful attitude toward friends, family members, or adults Threatens to or has run away from home Deliberately breaks rules, laws, or expectations Engages in inappropriate sexual behavior (e.g. sexually active, exhibits self, sexual abuse toward family members or others Is irritable Becomes angry enough to be threatening to others Has difficulty concentrating, thinking clearly, or attending to tasks Seems to stir up trouble when bored Is unusually demanding Complains of nightmares, difficulty getting to sleep, oversleeping, or waking up from sleep too early Is overly anxious or nervous Has friends of whom I don't approve Doesn't have or keep friends Has difficulty waiting his/her turn in activities or conversations

Other

Please list any substance use:

Please list what services or agencies he/she has been involved in up to now:

Explain why you are requesting a LCT: