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Thank you for your interest in the Zepf Center's MST Program!
To submit an application on a youth's behalf, please completely fill out the form below and press submit. Alternatively, you may download a physical application HERE and turn it in to the Zepf Center Woodruff location(424 W. Woodruff Ave., Toledo, OH 43604).
Additional materials are requested, if available, including: Summary of Prior Offending, Recent Mental Health Evaluation, and Recent Educational Evaluation. Please attach these materials to your physical application, or send them through e-mail to [email protected]. |
Youth Name | |
Youth Gender | |
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Date of Birth
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Race of Youth | |
Address | |
City | |
State | |
Zip | |
Telephone(all known) | |
Current IQ(if known): | |
Parent/Guardian/Caregiver | |
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What is the caregiver's relationship to the youth?
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Household Member Names | |
Key Participants Involved | |
Please identify strengths of the youth's family | |
Please identify strengths of the youth | |
Type of Insurance | |
School | |
Number of Days in Detention in the Last 90 Days | |
Number of Days Suspended in the Last 90 Days | |
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Is Youth Currently Involved in Mental Health and/or AoD Services?
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Please indicate which service(s) the youth is currently involved in: |
Children's Services
Juvenile Court
Mental Health Service Provider
Other(Please indicate below)
None
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Other | |
[If Yes, please provide name of provider and clinician(s)] | |
Referrer | |
Referrer Email & Phone Number | |
Referrer Relationship to Youth | |
Youth Behavioral Characteristics |
Violent behavior causing injury
Non-violent aggressive behavior
Crimes against person(e.g. robbery or theft)
Crimes against property
Drug-related criminal offending
Drug abuse or dependence
Evidence of drug use
Status offending(e.g. curfew or underage drinking)
Non-compliance with probation or court order
Non-compliance with family rules & expecations
Family is very active in youth's treatment
Family is willing to continue assisting youth
Other(please elaborate below)
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Other | |
Please indicate highest priority behaviors | |
Youth-School Characteristics |
Expelled or dropped out of formal education
Attending alternative school setting -- not mainstream
Multiple suspensions for problem behavior
High association with antisocial school peers
Low affiliation with pro-social school peers
Poor relationships with school staff
Attendance problems -- risk of expulsion
Academic problems -- risk of failure
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Youth-Peer Characteristics |
Gang membership or strong affiliation
High affiliation with mostly antisocial peers
Mixed antisocial and pro-social peers
Low affiliation with pro-social peers
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Desired Outcomes for Referral to MST Services |
Retain in school/vocational efforts
Reduce substance use
Improve youth and family behavioral management skills
Improve youth and family pro-social involvement
Prevent out of home placement
Improve family problem solving skills
Reduce mental illness symptoms
Improve family communication and cohesiveness
Reduce aggressive and criminal behaviors
Other(please explain below)
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Other | |
More Background Information | |
Supplemental Documents | |
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