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Case Information
Case Type
*
- Select -
Child/Family Focused Case
Programmatic Case
Targeted Case (Deprecated DO NOT USE)
Child Initials
*
Program Name
*
Referral Source
*
- Select -
Provider
Resource Center Staff
Social Emotional Consultant
Substance Abuse Prevention Specialist
Self-referral
Other (eg. Teacher, Guardian, etc.)
Other Referral Source
*
Classrooms Served
Target Classroom Name
County/Program ID
*
Consultant ID
*
Child Care Provider ID
*
Child ID
*
Serving County
- Select County/Program ID -
003 (Allegan)
025 (Genesee)
031 (Houghton / Baraga / Keweenaw / Ontonagon)
033 (Clinton / Eaton / Ingham)
037 (Mecosta / Osceola / Clare / Isabella (not serving in this county))
039 (Kalamazoo)
050 (Macomb)
061 (Muskegon)
063 (Oakland)
041 (Kent)
046 (Lenawee)
073 (Saginaw)
074 (St. Clair / Sanilac / Lapeer / Tuscola / Huron)
077 (Schoolcraft / Marquette / Dickinson / Menominee / Delta / Alger / Gogebic / Luce / Chippewa / Mackinac)
080 (Van Buren)
082 (Wayne - Development Centers)
182 (Wayne - The Guidance Center)
282 (Wayne - Hegira)
000 (Test County)
001 (Test County)
123 (Test County)
Insurance Information
Does the child have Medicaid/MiChild coverage?
- Select -
Yes
No
Unknown
Demographic Information
Age (in months) at Pre-assessment
*
Gender
*
- Select -
Female
Male
Race
*
- Select -
African American
American Indian/Alaska Native
Asian
Native Hawaiian/Pacific Islander
White
Of Hispanic or Latino descent
Multiracial/Biracial
Other
Unknown
Refused Identification
Ethnicity
*
- Select -
Hispanic or Latino
Non-Hispanic or Latino
Step Complete
Form Status
Case Status
Opened
Closed Complete
Closed Incomplete
Additional Information
Step Complete
Case Status
Active
Closed - Complete
Closed - Transitioned
Closed - Early Exit
Closed - Incomplete (DEPRECATED - please select Complete, Transitioned or Early Exit)
Case Notes
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