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MST Program Referral Form

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 mst@zepfcenter.org.

Youth Name
Youth Gender
Date of Birth
Race of Youth
Address
City
State
Zip
Telephone(all known)
Current IQ(if known):
Parent/Guardian/Caregiver
What is the caregiver's relationship to the youth?
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
Is Youth Currently Involved in Mental Health and/or AoD Services?
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
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)
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
 
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
 
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)
Other
More Background Information
Supplemental Documents

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Integrated care is the coordination of general and behavioral health care needs in an effort to treat not just the body but the mind.

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