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ffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffffff0c00000040092900aa00000000000000f800cb0100000000040000002701ffff030000000000}}}{\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\insrsid7175635 \tab \tab \tab \tab \tab \tab \tab \tab \tab }{\rtlch\fcs1 \af1 \ltrch\fcs0 \loch\af1\hich\af1\dbch\af35\insrsid1659336\charrsid16403344 

\par }\pard \ltrpar\ql \fi720\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid4289281 {\rtlch\fcs1 \af1 \ltrch\fcs0 \loch\af1\hich\af1\dbch\af35\insrsid1659336\charrsid8795468 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16403344 {\rtlch\fcs1 \af1 \ltrch\fcs0 \loch\af1\hich\af1\dbch\af35\insrsid1659336\charrsid16403344 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid16403344 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid3948017 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid3948017\charrsid16403344 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7175635 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7175635\charrsid16403344 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16403344 {\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \b\f1\fs32\insrsid1659336\charrsid3948017 SECURE TREATMENT PROGRAM

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336\charrsid16403344 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\fs32\insrsid1659336\charrsid3948017 REFERRAL PACKAGE

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3948017 

\par 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid3948017\charrsid16403344 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid10959786 1199 CARLING AVENUE}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid3948017 

\par O}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid10959786 TTAWA}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid3948017 , ONTARIO

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid10959786 K1Z 8N3}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid3948017 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid3948017 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid3948017\charrsid3948017 

\par }\pard \ltrpar\ql \fi720\li2160\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin2160\itap0\pararsid944323 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\ul\insrsid10959786\charrsid7041238 INTAKE}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\f1\fs24\ul\insrsid7041238\charrsid7041238  DEPARTMENT}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\ul\insrsid10959786\charrsid7041238 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid10959786 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid3948017 PHONE:        }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid10959786 613-728-1946 EXT. 236}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid3948017 



\par FAX:              }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid10959786 613-728-4986}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \fs24\loch\af1\hich\af1\dbch\af35\insrsid1659336\charrsid3948017 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16403344 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336\charrsid16403344 

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\par }\pard \ltrpar\qc \li0\ri0\widctlpar\brdrb\brdrs\brdrw30\brsp20 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7175635 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\fs28\loch\af1\hich\af1\dbch\af35\insrsid7175635\charrsid5460992 

\hich\af1\dbch\af35\loch\f1 OVERVIEW}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\fs28\loch\af1\hich\af1\dbch\af35\insrsid6061312\charrsid5460992 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16403344 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\ul\insrsid3948017\charrsid5460992 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid1659336\charrsid5460992 INTRODUCTION

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid10432338\charrsid5460992 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid13116843 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid6257268 

The Secure Treatment program (six beds) of the Roberts/Smart Centre provides treatment for adolescents with a mental disorder, who have demonstrated that they are a danger to themselves or others and that they require services in a highly secure facility.

  Admission to the secure treatment program is prescribed by legislation (}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid13116843\charrsid6257268 Child and Family Services Act (CFSA), R.S.O. 1990, Chapter C.11}{\rtlch\fcs1 \af1\afs22 

\ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid6257268 , section 114).

\par 

\par The program offers an on-site classroom, where students are able to earn credits toward their high school diploma while in care, under a partnership between the Roberts/Smart Centre and the }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 

\f31506\fs22\insrsid13116843\charrsid6257268 M.F. McHugh Education Centre}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid6257268 .\line }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336 

\par }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid6257268 Admission criteria for the secure t

reatment program can be found in the Child and Family Services Act, R.S.O. 1990, Chapter C.11, section 117.  It is strongly recommended that persons wishing to make a referral review this legislation before doing so, and, if possible, consult with legal c

ounsel.  Where there are questions specific to the program at the Roberts/Smart Centre, the }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid13116843\charrsid6257268 Intake Coordinator}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 

\f31506\fs22\cf1\insrsid13116843\charrsid6257268  will be pleased to provide information.  Note especially the sections related to consent, in particular where the client is over sixteen years of age.\line 

\par }{\rtlch\fcs1 \ab\af1\afs22 \ltrch\fcs0 \cs24\b\f31506\fs22\cf1\insrsid13116843\charrsid13116843 Length of Stay}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid13116843 \line 

\par Under the }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid13116843\charrsid13116843 legislation}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid13116843 

, a Judge may order an adolescent to be committed to the Secure Treatment program for a period up to 180 days, which may be extended by judicial order.  A young person may stay in the Secure Treatment program unti

l six months after his/her eighteenth birthday.

\par  \line }{\rtlch\fcs1 \ab\af1\afs22 \ltrch\fcs0 \cs24\b\f31506\fs22\cf1\insrsid13116843\charrsid13116843 Plans of Care/Treatment}{\rtlch\fcs1 \ab\af1\afs22 \ltrch\fcs0 \b\f31506\fs22\cf1\insrsid13116843\charrsid13116843 \line 

\par }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid13116843 

Plans of care are developed for each young person placed in the secure unit.  The professional clinical staff, with the collaboration of the adolescent, the parents, residential sta

ff, and other concerned professionals, is responsible for the development of the plans of care.\line 

\par }{\rtlch\fcs1 \ab\af1\afs22 \ltrch\fcs0 \cs24\b\f31506\fs22\cf1\insrsid13116843\charrsid13116843 Discharge}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid13116843 \line 

\par Generally clients are discharged upon the expiry of the secure treatment order; however, upon the recommendation of the Clinical Supervisor, the Executive Director of the Centre may discharge an adolescent at any point.\line \line }{\rtlch\fcs1 

\ab\af1\afs22 \ltrch\fcs0 \b\f31506\fs22\cf1\insrsid13116843\charrsid13116843 Emergency (}{\rtlch\fcs1 \ab\af1\afs22 \ltrch\fcs0 \cs24\b\f31506\fs22\cf1\insrsid13116843\charrsid13116843 Short-Term) Admissions}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 

\f31506\fs22\cf1\insrsid13116843\charrsid13116843 \line 

\par While the CFSA (Section 124 (2)) provides for emergency admissions to secure treatment programs for terms up to 30 days, the Roberts/Smart Centre offers these opportunities }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 

\f31506\fs22\ul\cf1\insrsid13116843\charrsid13116843 only in rare circumstances}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid13116843 .

\par 

\par All requests for admissions under this section }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\ul\cf1\insrsid13116843\charrsid13116843 must}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid13116843  be discussed with the }{

\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid13116843\charrsid13116843 Intake Coordinator}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid6257268  prior to the application being made.}{\rtlch\fcs1 \af1\afs22 

\ltrch\fcs0 \f31506\fs22\cf1\insrsid13116843\charrsid13116843 

\par 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16403344 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid1659336\charrsid13116843 The focus of the secure treatment program is two}{

\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid13116843 -}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid1659336\charrsid13116843 fold:

\par }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid10432338\charrsid13116843 

\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\lang4105\langfe1033\langnp4105\insrsid13008623\charrsid13116843 \hich\af31506\dbch\af0\loch\f31506 1.\tab}}\pard \ltrpar\ql \fi-360\li360\ri0\widctlpar

\jclisttab\tx360\wrapdefault\aspalpha\aspnum\faauto\ls3\adjustright\rin0\lin360\itap0\pararsid16403344 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid13008623\charrsid13116843 T}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 

\f31506\fs22\insrsid1659336\charrsid13116843 o stabilize the youth and clarify their mental health needs within the secure setting and }{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid6061312\charrsid13116843 

\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\lang4105\langfe1033\langnp4105\insrsid13008623\charrsid13116843 \hich\af31506\dbch\af0\loch\f31506 2.\tab}}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 

\f31506\fs22\insrsid13008623\charrsid13116843 T}{\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid1659336\charrsid13116843 o allow the youth to make sufficient gains that they may continue their treatment in a less secure setting.

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid16403344 {\rtlch\fcs1 \af1\afs22 \ltrch\fcs0 \f31506\fs22\insrsid1659336\charrsid13116843 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid13116843 

\par 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid7041238 

\par 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid13116843 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid1659336\charrsid5460992 REFERRAL PROCESS

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid7627174 Admission into the Secure Treatment Program goes through the Family Courts and is subject to }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid4485427 

the criteria set out in section 114 of the Child and Family Services Act.  }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid7627174 It is critical that all information be filled out clearly and completely in order for th

e referral to be reviewed and considered for the secure treatment program.  }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par 

\par The completed package is to be returned to the attention of the }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid13116843 Intake Coordinator}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 . }{\rtlch\fcs1 \af1\afs23 

\ltrch\fcs0 \f1\fs23\insrsid13116843  }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 The program will only process referrals when it is in receipt of the }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 

\b\f1\fs23\ul\insrsid1659336\charrsid5460992 complete}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992  referral package.  The }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid13116843 Intake Coordinator}{\rtlch\fcs1 

\af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid13116843\charrsid5460992  }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 will advise the referring person/agency of the status }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 

\f1\fs23\insrsid14106331\charrsid5460992 of the referral once the}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992  review is complete and every }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid13116843 3}{\rtlch\fcs1 

\af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 0 days thereafter}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid8795468\charrsid5460992  if the youth is placed on }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid13116843 a}{

\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid8795468\charrsid5460992  waiting list}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 .

\par 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid14106331\charrsid5460992 If the youth is }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid13116843 deemed }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid14106331\charrsid5460992 appropriate}{

\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992  }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid13116843 for admission to the program, he/she}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

 will be placed on the waiting list}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid13116843  (if one exists at the time of the referral)}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 , }{\rtlch\fcs1 \af1\afs23 

\ltrch\fcs0 \f1\fs23\insrsid14106331\charrsid5460992 and prioritized by }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 need.  When a bed}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid14106331\charrsid5460992 

 becomes available the youth}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992  in }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid14106331\charrsid5460992 the }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 

\f1\fs23\insrsid1659336\charrsid5460992 most need will receive the documents required for a Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}Treatment{\*\xmlclose} Application Hearing including a signed consent by the {\*\xmlopen\xmlns2{\factoidname 

PersonName}}Administrator{\*\xmlclose} of the Program, an Application Form and the Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}Treatment{\*\xmlclose} Order, which the Judge will be required to complete for admission. }{\rtlch\fcs1 \af1\afs23 

\ltrch\fcs0 \f1\fs23\insrsid1659336 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid13116843 

\par NOTE:  youth with outstanding matters in the Youth Court related

 to the Youth Criminal Justice Act are not precluded from being considered for admission to the secure treatment program, however, these matters must be identified at the time of the referral and any subsequent charges prior to admission must be reported 

to the Intake Coordinator.}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid13116843\charrsid5460992 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\nooverflow\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid12086670\charrsid5460992 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid7175635\charrsid5460992 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid7175635 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid13116843 

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\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid4289281 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid13116843 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid13116843\charrsid5460992 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid7175635\charrsid5460992 

\par 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\brdrb\brdrs\brdrw30\brsp20 \wrapdefault\nooverflow\faauto\rin0\lin0\itap0\pararsid7175635 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid7175635\charrsid5460992 OVERVIEW

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\nooverflow\faauto\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid7175635\charrsid5460992 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid16131359 COURT APPLICATION }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid1659336\charrsid5460992 PROCESS

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid2843758 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid2843758\charrsid5460992 Applicants are responsible for managing the court process for initial application and extensions as required. The program will supply a status report on the 

criteria for extension applications.}{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid2843758 

\par 

\par ADMISSION CRITERIA }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \ai\af1\afs23 \ltrch\fcs0 \i\f1\fs23\insrsid12086670\charrsid5460992 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 The Court may order that a child be committed to a Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}Treatment{\*\xmlclose} Program only where the Court is satisfied that,



\par 

\par (a)\tab the child has a mental disorder

\par 

\par }\pard \ltrpar\ql \fi-720\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid7630824 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 (b)\tab the

 child has, as a result of the mental disorder, within forty-five days immediately preceding,

\par }\pard \ltrpar\ql \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid7630824 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 (i)\tab the application under subsection 114(1)

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard \ltrpar\ql \fi-720\li1440\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin1440\itap0\pararsid7630824 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 (ii)\tab the child\rquote 

s detention or custody under the Young Offenders Act ({\*\xmlopen\xmlns2{\factoidname place}}{\*\xmlopen\xmlns2{\factoidname country-region}}Canada{\*\xmlclose}{\*\xmlclose}) or under the Provincial Offences Act, or

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard \ltrpar\ql \fi-720\li1440\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin1440\itap0\pararsid7630824 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 (iii)\tab the child\rquote 

s admission to a psychiatric facility under the Mental Health Act as an involuntary patient,

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard \ltrpar\ql \fi720\li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

caused or attempted to cause serious bodily harm to himself, herself or another person.

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par (c)\tab the child has,

\par }\pard \ltrpar\ql \fi-720\li1440\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin1440\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 (i)\tab within the twelve months immedia

tely preceding the application, but on another occasion than referred to in clause (b), caused, attempted to cause or by words or conduct made a substantial threat to cause serious bodily harm to himself, herself or another person, or

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard \ltrpar\ql \fi-720\li1440\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin1440\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 (ii)\tab in committing t

he act or attempt referred to in clause (b), caused or attempted to cause a person\rquote s death;

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard \ltrpar\ql \fi-720\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 (d)\tab the Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}

Treatment{\*\xmlclose} Program would be effective to prevent the child from causing or attempting to cause serious bodily harm to himself, herself or another person;

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard \ltrpar\ql \fi-720\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 (e)\tab treatment appropriate for the child\rquote 

s mental disorder is available at the place of Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}Treatment{\*\xmlclose} to which the application relates; and

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard \ltrpar\ql \fi-720\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 (f)\tab 

no less restrictive method of providing treatment appropriate for the child\rquote s mental disorder is appropriate in the circumstances.

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard\plain \ltrpar\s18\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \ab\af0\afs20\alang1025 \ltrch\fcs0 \b\fs24\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 

\f1\fs23\insrsid7617615 

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 NOTE:  WHERE THE CHILD IS LESS THAN TWELVE YEARS OLD, THE CONSENT OF THE MINISTER IS REQUIRED.  

\par }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 

\f1\fs23\insrsid1659336\charrsid5460992 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid1659336\charrsid5460992 

\par 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid1659336 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid4485427 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid4485427\charrsid5460992 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid7175635\charrsid5460992 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid12086670\charrsid5460992 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\brdrb\brdrs\brdrw30\brsp20 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7175635 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid7175635\charrsid5460992 OVERVIEW}{\rtlch\fcs1 

\ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid8795468\charrsid5460992 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7175635 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid7175635\charrsid5460992 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid12086670\charrsid5460992 

\par }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\ul\insrsid1659336\charrsid5460992 APPLICATION FOR ADMISSION

\par }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par Admission to the Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}Treatment{\*\xmlclose} Program requires that an application be made to the {\*\xmlopen\xmlns2{\factoidname address}}{\*\xmlopen\xmlns2{\factoidname Street}}Provincial Court{\*\xmlclose}

{\*\xmlclose} under Section 114(1) of the Child and Family Services Act.

\par 

\par Any one of the following persons may, with the administrator\rquote s written consent, apply to the court for an order for the child\rquote s commitment to a Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}Treatment{\*\xmlclose} Program:

\par 

\par Where the child is }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \b\f1\fs23\insrsid1659336\charrsid4485427 less than sixteen years}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992  of age;\tab \tab \tab \tab 

\par 

\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\lang4105\langfe1033\langnp4105\insrsid1659336\charrsid5460992 \hich\af1\dbch\af0\loch\f1 1.\tab}}\pard \ltrpar\ql \fi-360\li720\ri0\widctlpar

\jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls1\adjustright\rin0\lin720\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 The child\rquote s parent,

\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\lang4105\langfe1033\langnp4105\insrsid1659336\charrsid5460992 \hich\af1\dbch\af0\loch\f1 2.\tab}A person other than an administrator who is caring for the child, if the child\rquote 

s parent consents to the application, or

\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\lang4105\langfe1033\langnp4105\insrsid1659336\charrsid5460992 \hich\af1\dbch\af0\loch\f1 3.\tab}A society that 

has custody of the child under an order made under Part III (Child Protection)

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par Where the child is }{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \b\f1\fs23\insrsid1659336\charrsid4485427 sixteen years of age or more}{\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 ;\tab \tab \tab \tab 

\par 

\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\lang4105\langfe1033\langnp4105\insrsid1659336\charrsid5460992 \hich\af1\dbch\af0\loch\f1 1.\tab}}\pard \ltrpar\ql \fi-360\li720\ri0\widctlpar

\jclisttab\tx720\wrapdefault\aspalpha\aspnum\faauto\ls2\adjustright\rin0\lin720\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 The child,

\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\lang4105\langfe1033\langnp4105\insrsid1659336\charrsid5460992 \hich\af1\dbch\af0\loch\f1 2.\tab}The child\rquote s parent, if the child consents to the application\tab \tab 

\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\lang4105\langfe1033\langnp4105\insrsid1659336\charrsid5460992 \hich\af1\dbch\af0\loch\f1 3.\tab}A society that has custody of the child under 

and order made under Part III (Child Protection), if the child consents to the application, or

\par {\listtext\pard\plain\ltrpar \rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\lang4105\langfe1033\langnp4105\insrsid1659336\charrsid5460992 \hich\af1\dbch\af0\loch\f1 4.\tab}A physician\tab \tab \tab \tab \tab \tab \tab \tab 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par On the basis of this application, the Court may order the child into Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}Treatment{\*\xmlclose} for a period up to 180 days if the criteria for admission are met.

\par 

\par }\pard \ltrpar\ql \fi-1440\li1440\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin1440\itap0 {\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 \b\f1\fs23\insrsid1659336\charrsid5460992 Note:\tab }{\rtlch\fcs1 \ab\af1\afs23 \ltrch\fcs0 

\b\f1\fs23\insrsid15426902\charrsid5460992 

\par 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid2175070 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

Where a child is committed to a secure treatment program on a society\rquote s application and the period specified in the court\rquote s order is greater than sixty days, the child shall be released on a day sixty days after the child\rquote s admission 

to the secure treatment program unless before that day,

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par }\pard \ltrpar\ql \li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid2175070 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 (a)\tab The child\rquote s parent consents to the child

\rquote s commitment for a longer period; or

\par (b)\tab The child is made a Crown or Society ward under Part III (Child Protection),

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0 {\rtlch\fcs1 \af1\afs23 \ltrch\fcs0 \f1\fs23\insrsid1659336\charrsid5460992 

\par But in no case shall the child be committed to the Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}Treatment{\*\xmlclose} Program for longer than the period specified under subsection (1). R.S.O. 1990, c. C.11,s 118 (1, 2).

\par 

\par 

\par 

\par 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid5460992 

\par 

\par 

\par 

\par 

\par 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid16131359 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid16131359\charrsid5460992 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\brdrb\brdrs\brdrw30\brsp20 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6622801 {\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \b\f1\fs32\insrsid6622801 PART 1

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6622801 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5404115 Child\rquote s Name:  ______}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid15742037 _________________________      }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5404115 Da}{

\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid15742037 te of Birth:  __________   Sex:  ___}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid8863366 

\par }{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f1\fs16\insrsid5404115                                         (First)                      }{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f1\fs16\insrsid10834360         }{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 

\b\f1\fs16\insrsid5404115 (Middle}{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f1\fs16\insrsid10834360 )                             (Last)                         }{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f1\fs16\insrsid15742037                     }{

\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f1\fs16\insrsid10834360  (month/day/year)}{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f1\fs16\insrsid5404115\charrsid5404115 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid8863366 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid10834360 Applicant Name:  ___________________________          Telephone:  ____________________

\par 

\par Organization / Relationship to Child:  ______________________________________________

\par 

\par Mailing Address:  _______________________________________________________________}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5404115 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid10834360 

\par _______________________________________________________________________________

\par 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid723480 Legal Guardian:  ________________________________________________________________

\par \tab \tab \tab       }{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f1\fs16\insrsid723480 Name                                                                               Status i.e. Crown Ward, Adoptive Parent, Bio. Parent               }{\rtlch\fcs1 

\af1\afs16 \ltrch\fcs0 \b\f1\fs16\insrsid723480\charrsid723480 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid723480 _______________________________________________________________________________

\par }{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 \b\f1\fs16\insrsid723480 Mailing Address                                                                                                                            Telephone Number}{\rtlch\fcs1 \af1\afs16 \ltrch\fcs0 

\b\f1\fs16\insrsid723480\charrsid723480 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid723480 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid15742037 Is the child consenting to the a}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid10834360 pplication?   _________________________________________

\par 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid15742037 Is the c}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid10834360 hild\rquote s parent/guardian consenting}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid15742037 

 to the application?  __________________________}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid10834360 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid2126598 

\par Where is the child currently residing}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid14159425 ?}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid2126598   ______________________________________________

\par 

\par _______________________________________________________________________________}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid2126598\charrsid2126598 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid15742037 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid10818665 Current/outstanding matters under the Youth Criminal Justice Act }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid10818665 (include charges, dates, locations etc)}{\rtlch\fcs1 \af1\afs24 

\ltrch\fcs0 \b\f1\fs24\insrsid10818665 :  }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid10818665\charrsid10818665 ________________________________________________________________________}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid10818665 _______________}{

\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid10818665\charrsid10818665 ____

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid10818665 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid10818665\charrsid10818665 _______________________}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid10818665 ________________}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid10818665\charrsid10818665 

_________________________________________________________

\par 

\par ________________________}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid10818665 ________________}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\insrsid10818665\charrsid10818665 ________________________________________________________

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid5404115 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid12853303 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid1659336\charrsid12853303 ADMISSION CRITERIA}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 

\b\f1\fs28\ul\insrsid4272861\charrsid12853303  1}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid1659336\charrsid12853303 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336\charrsid7880916 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 Provide details that the child has a mental disorder, if you are unfamiliar with DSM-IV multiaxial d}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4272861 

iagnosis insert }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 the diagnosis}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4272861  as Axis I}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid4272861 .}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5404115 Please attach the psychiatric report.}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5404115\charrsid5404115 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 

\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth3\trwWidth11088\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\clcbpat17\cltxlrtb\clftsWidth3\clwWidth11088\clcbpatraw17 \cellx10980\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid15742037\charrsid15742037 Physician who completed diagnosis:          }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid15742037 

                         }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid15742037\charrsid15742037 Agency:

\par Address/Telephone Number:}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid15742037 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15742037\charrsid4272861 \trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11088\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb

\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth11088\clcbpatraw17 \cellx10980\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11088\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb

\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4788\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5220\clshdrawnil \cellx9900

\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1080\clshdrawnil \cellx10980\pard\plain \ltrpar

\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15742037 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid5404115 Axis}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid4272861 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5404115 Diagnosis}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid1659336\charrsid4272861 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5404115 Date}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4272861\charrsid5404115 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid4272861 

\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth3\trwWidth11088\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4788\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5220\clshdrawnil \cellx9900\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1080\clshdrawnil \cellx10980\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid4272861 Axis I}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 {\field{\*\fldinst SYMBOL 240 \\f "Symbol" \\s 12}{\fldrslt\f3\fs24}}}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861  Principal Diagnosis\cell 

}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 \cell }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid4272861 

\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth3\trwWidth11088\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4788\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5220\clshdrawnil \cellx9900\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1080\clshdrawnil \cellx10980\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid4272861 Axis II}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 {\field{\*\fldinst SYMBOL 240 \\f "Symbol" \\s 12}{\fldrslt\f3\fs24}}}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861  Principal Diagnosis}{

\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 \cell \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid4272861 \trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth3\trwWidth11088\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb

\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4788\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5220\clshdrawnil \cellx9900

\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1080\clshdrawnil \cellx10980\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid4272861 Axis III

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4272861\charrsid4272861 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid4272861 

\trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth3\trwWidth11088\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4788\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5220\clshdrawnil \cellx9900\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1080\clshdrawnil \cellx10980\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid4272861 Axis IV

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4272861\charrsid4272861 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid4272861 

\trowd \irow5\irowband5\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth3\trwWidth11088\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4788\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5220\clshdrawnil \cellx9900\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1080\clshdrawnil \cellx10980\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid4272861 Axis V

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4272861\charrsid4272861 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid4272861 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid4272861 

\trowd \irow6\irowband6\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth3\trwWidth11088\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4788\clshdrawnil \cellx4680\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5220\clshdrawnil \cellx9900\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1080\clshdrawnil \cellx10980\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {

\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336\charrsid7880916 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14159425 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid4272861\charrsid14159425 ADMISSION CRITERIA 2}{\rtlch\fcs1 \ab\af1\afs28 

\ltrch\fcs0 \b\f1\fs28\insrsid4272861\charrsid14159425 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid4272861 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid2768585 Provide details that the child has, as a result of the mental disorder, }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid11015570 within 

forty-five days}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid2768585  immediately preceding,}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid2768585  }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid2768585 

\par 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14159425 {\*\protstart ffff010000000000}{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid14159425 

{\*\bkmkstart Check1} FORMCHECKBOX }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1996910 {\*\datafield 010000001400000006436865636b3100000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20{\*\ffname Check1}\ffdefres0}}}}{\fldrslt }}

\sectd \ltrsect\linex0\headery432\footery432\endnhere\titlepg\sectdefaultcl\sectrsid12086670\sftnbj {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid14159425 {\*\bkmkend Check1}{\*\protend ffff010000000000}\tab }{\rtlch\fcs1 \ab\af1\afs24 

\ltrch\fcs0 \f1\fs24\insrsid5712095 t}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid5712095\charrsid2768585 he application under subsection 114(1)}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid5712095 , or

\par }\pard \ltrpar\ql \fi-720\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid14159425 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid14159425 {\*\bkmkstart Check2} FORMCHECKBOX }

{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1996910 {\*\datafield 010000001400000006436865636b3200000000000000000000000000}{\*\formfield{\fftype1\fftypetxt0\ffhps20{\*\ffname Check2}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect

\linex0\headery432\footery432\endnhere\titlepg\sectdefaultcl\sectrsid12086670\sftnbj {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid14159425 {\*\bkmkend Check2}\tab }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid2768585 t}{\rtlch\fcs1 

\ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid2768585 he child\rquote s detention or custody under the You}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid5712095 th Criminal Justice }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid2768585 Act or under}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid2768585  the Provincial Offences Act, or

\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid14159425 {\*\bkmkstart Check3} FORMCHECKBOX }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1996910 {\*\datafield 

650000001400000006436865636b3300000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check3}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery432\footery432\endnhere\titlepg\sectdefaultcl\sectrsid12086670\sftnbj {

\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid14159425 {\*\bkmkend Check3}\tab }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid2768585 t}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid2768585 he child\rquote 

s admission to a psychiatric facility under the Mental Health Act as an involuntary patient,

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid2768585 

\par caused or attempted to cause }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid14159425 serious bodily harm to himself, herself or another person}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid2768585 .}{

\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid1659336\charrsid7880916 

\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\clcbpat17\cltxlrtb\clftsWidth3\clwWidth5148\clcbpatraw17 \cellx5040\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth1170\clcbpatraw17 \cellx6210\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth4680\clcbpatraw17 \cellx10890\pard\plain \ltrpar

\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14159425 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid14159425 Incident }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid2768585 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid14159425 Date}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid1659336\charrsid2768585 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid14159425 Outcome}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid526756\charrsid2768585 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 

\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\clcbpat17\cltxlrtb\clftsWidth3\clwWidth5148\clcbpatraw17 \cellx5040\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth1170\clcbpatraw17 \cellx6210\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth4680\clcbpatraw17 \cellx10890\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 

\trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5148\clshdrawnil \cellx5040\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth1170\clshdrawnil \cellx6210\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680\clshdrawnil \cellx10890\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\insrsid1659336\charrsid7880916 \cell \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14159425\charrsid7880916 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 \trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5148\clshdrawnil \cellx5040\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1170\clshdrawnil \cellx6210\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680\clshdrawnil \cellx10890\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\insrsid1659336\charrsid7880916 \cell \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14159425\charrsid7880916 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 \trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5148\clshdrawnil \cellx5040\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1170\clshdrawnil \cellx6210\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680\clshdrawnil \cellx10890\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\insrsid1659336\charrsid7880916 \cell \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14159425\charrsid7880916 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 \trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5148\clshdrawnil \cellx5040\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1170\clshdrawnil \cellx6210\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680\clshdrawnil \cellx10890\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\insrsid1659336\charrsid7880916 \cell \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14159425\charrsid7880916 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 \trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5148\clshdrawnil \cellx5040\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1170\clshdrawnil \cellx6210\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680\clshdrawnil \cellx10890\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid552298 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid552298\charrsid4272861 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid552298\charrsid7880916 \cell }{\rtlch\fcs1 \af1 

\ltrch\fcs0 \f1\insrsid552298 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14159425\charrsid7880916 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid552298\charrsid7880916 \trowd \irow5\irowband5\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 

\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb

\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5148\clshdrawnil \cellx5040\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1170\clshdrawnil \cellx6210

\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4680\clshdrawnil \cellx10890\row }\pard \ltrpar

\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14159425 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid14159425 Please attach supporting documentation i.e. incident reports, police reports}{

\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid14159425\charrsid14159425 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid1659336 

\par }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid14159425 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14159425 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid4272861\charrsid14159425 ADMISSION CRITERIA }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 

\b\f1\fs28\ul\insrsid15423151\charrsid14159425 3}{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid4272861\charrsid14159425 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid4272861 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid8200189 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4272861\charrsid8200189 Pro}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid8200189 vide details that the child has,}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid14106331  as a result of the mental disorder,}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid13112988\charrsid8200189  

}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid8200189 in the }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid11015570 twelve months}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid8200189  immediately preceding the application, but on another occasion than referred to in c}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid13112988\charrsid8200189 riteria 2}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid8200189 ,}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid8200189 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid10255227 

\par }\pard \ltrpar\ql \fi-720\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid6108698 {\field\fldpriv{\*\fldinst {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6108698 {\*\bkmkstart Check4} FORMCHECKBOX }{

\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1996910 {\*\datafield 650000001400000006436865636b3400000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check4}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect

\linex0\headery432\footery432\endnhere\titlepg\sectdefaultcl\sectrsid12086670\sftnbj {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6108698 {\*\bkmkend Check4}\tab }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid8200189 

caused, attempted to cause or by words or conduct made a }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid14159425 substantial threat to cause serious bodily harm to himself, herself or another person}{\rtlch\fcs1 \ab\af1\afs24 

\ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid8200189 , }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid14159425 or}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid8200189 

\par }{\field\fldpriv{\*\fldinst {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6108698 {\*\bkmkstart Check5} FORMCHECKBOX }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1996910 {\*\datafield 

650000001400000006436865636b3500000000000000000000000000}{\*\formfield{\fftype1\ffres25\fftypetxt0\ffhps20{\*\ffname Check5}\ffdefres0}}}}{\fldrslt }}\sectd \ltrsect\linex0\headery432\footery432\endnhere\titlepg\sectdefaultcl\sectrsid12086670\sftnbj {

\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6108698 {\*\bkmkend Check5}\tab }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid8200189 in committing the act or attempt referred to in c}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid13112988\charrsid8200189 riteria 2}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid8200189 , }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid14159425 caused or attempted to cause a person

\rquote s}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid8200189  death;

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid1659336\charrsid7880916 

\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\clcbpat17\cltxlrtb\clftsWidth3\clwWidth6318\clcbpatraw17 \cellx6210\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth900\clcbpatraw17 \cellx7110\clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth3707\clcbpatraw17 \cellx10817\pard\plain \ltrpar

\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid14159425 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid14159425 Incident }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid10255227\charrsid8200189 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid14159425 Date}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid10255227\charrsid8200189 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid14159425 Outcome}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid10255227\charrsid2768585 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10255227\charrsid7880916 

\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\clcbpat17\cltxlrtb\clftsWidth3\clwWidth6318\clcbpatraw17 \cellx6210\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth900\clcbpatraw17 \cellx7110\clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth3707\clcbpatraw17 \cellx10817\row \ltrrow}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl

\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6318\clshdrawnil \cellx6210\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth900\clshdrawnil \cellx7110\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3707\clshdrawnil \cellx10817\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\tx360\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16153832 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 

\f1\insrsid16153832 

\par }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \f1\insrsid14159425\charrsid14159425 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\insrsid10255227\charrsid14159425 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10255227\charrsid7880916 \trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb

\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6318\clshdrawnil \cellx6210\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth900\clshdrawnil \cellx7110

\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3707\clshdrawnil \cellx10817\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid16153832 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid16153832 



\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14159425\charrsid14159425 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\insrsid10255227\charrsid14159425 \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10255227\charrsid7880916 \trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb

\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth6318\clshdrawnil \cellx6210\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth900\clshdrawnil \cellx7110

\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3707\clshdrawnil \cellx10817\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid10255227 



\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14159425\charrsid14159425 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid10255227\charrsid14159425 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10255227\charrsid7880916 

\trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth6318\clshdrawnil \cellx6210\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth900\clshdrawnil \cellx7110\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3707\clshdrawnil \cellx10817\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid10255227 



\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14159425\charrsid14159425 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid10255227\charrsid14159425 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10255227\charrsid7880916 

\trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth6318\clshdrawnil \cellx6210\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth900\clshdrawnil \cellx7110\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3707\clshdrawnil \cellx10817\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid10255227 



\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid14159425\charrsid14159425 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid10255227\charrsid14159425 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid10255227\charrsid7880916 

\trowd \irow5\irowband5\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth6318\clshdrawnil \cellx6210\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth900\clshdrawnil \cellx7110\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3707\clshdrawnil \cellx10817\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {

\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid1659336 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14159425 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid14159425 Please attach supporting documentation

 i.e. incident reports, police reports}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid14159425\charrsid14159425 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid12086670 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid14159425 

\par 

\par 

\par 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid14159425 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid7041238 A}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 

\b\f1\fs28\ul\insrsid16153832\charrsid14159425 DMISSION CRITERIA 4}{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid16153832\charrsid14159425 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid16153832\charrsid7880916 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid12349040 Provide details that no less restrictive method of providing treatme}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11015570 nt appropriate for the child\rquote s }{

\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid12349040 mental disorder is appropriate in the circumstances.}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid11015570 

\par }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid1659336\charrsid7880916 

\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\clcbpat17\cltxlrtb\clftsWidth3\clwWidth4158\clcbpatraw17 \cellx4050\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth1660\clcbpatraw17 \cellx5710\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth5198\clcbpatraw17 \cellx10908\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid1659336\charrsid12349040 Placement(s) }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6640240\charrsid12349040 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid12349040 Period}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11887178  of Placement}{

\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid12349040 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid12349040 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid6640240 Reason for breakdown/rejection }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid12349040 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 

\rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 \trowd \irow0\irowband0\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl

\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth4158\clcbpatraw17 \cellx4050\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\clcbpat17\cltxlrtb\clftsWidth3\clwWidth1660\clcbpatraw17 \cellx5710\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \clcbpat17\cltxlrtb\clftsWidth3\clwWidth5198\clcbpatraw17 \cellx10908\row \ltrrow

}\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4158\clshdrawnil \cellx4050\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1660\clshdrawnil \cellx5710\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5198\clshdrawnil \cellx10908\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 

\rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12349040\charrsid11887178 1.}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid11887178 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid12349040 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4015308 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4015308\charrsid11887178 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid11887178 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 

\trowd \irow1\irowband1\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4158\clshdrawnil \cellx4050\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1660\clshdrawnil \cellx5710\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5198\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid11887178\charrsid11887178 2.}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid11887178 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4015308 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4015308\charrsid11887178 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid11887178 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 

\trowd \irow2\irowband2\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4158\clshdrawnil \cellx4050\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1660\clshdrawnil \cellx5710\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5198\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid11887178 3.}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid2374252 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4015308 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4015308\charrsid11887178 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid11887178 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 

\trowd \irow3\irowband3\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4158\clshdrawnil \cellx4050\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1660\clshdrawnil \cellx5710\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5198\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid11887178 4. }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid11887178 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4015308 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4015308\charrsid11887178 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid11887178 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 

\trowd \irow4\irowband4\ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4158\clshdrawnil \cellx4050\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1660\clshdrawnil \cellx5710\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5198\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid11887178 5.}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid11887178 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4015308 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid4015308\charrsid11887178 \cell }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid11887178 \cell \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid1659336\charrsid7880916 

\trowd \irow5\irowband5\lastrow \ltrrow\ts11\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth4158\clshdrawnil \cellx4050\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth1660\clshdrawnil \cellx5710\clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth5198\clshdrawnil \cellx10908\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {

\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336\charrsid7880916 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6581125 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6581125 

Please attach supporting documentation i.e. letters of rejection, summary reports }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid6581125\charrsid14159425 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3047376 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid16471626 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\insrsid1659336\charrsid7880916 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6622801 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid6622801 

\par 

\par 

\par 

\par 

\par 

\par 

\par 

\par 

\par 

\par 

\par 

\par 

\par 

\par 

\par 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\brdrb\brdrs\brdrw30\brsp20 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6622801 {\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \b\f1\fs32\insrsid6622801 PART 2

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6622801 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid6622801\charrsid6622801 

\par }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid1659336\charrsid6622801 DISCHARGE PLAN

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid11146894 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid2819856\charrsid2819856 Provide a brief description of the 

placement/discharge plan for the child upon release from the secure treatment program.}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11146894 

\par }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\fs24\insrsid2819856 

\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11146894 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid2819856\charrsid2819856 Who is responsible for finding a placement upon discharge from the Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}

Treatment{\*\xmlclose} Program?}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid2819856\charrsid2819856 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2819856\charrsid2819856 \trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 

\trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11146894 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 

\f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {

\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 \trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11146894 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow2\irowband2\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11146894 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow3\irowband3\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11146894 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid2819856\charrsid2819856 Placement / Discharge Location}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4015308  if known}

{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid2819856\charrsid2819856 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid2819856 \trowd \irow4\irowband4\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 

\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 

\b\f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 

{\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 \trowd \irow5\irowband5\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow6\irowband6\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow7\irowband7\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6359864\charrsid6359864 Who will be responsible for the youth\rquote s health care needs?}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 

\b\f1\fs24\insrsid6359864 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 

\af0 \ltrch\fcs0 \insrsid6359864 \trowd \irow8\irowband8\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow9\irowband9\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow10\irowband10\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow11\irowband11\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11022969\charrsid11022969 Who will be responsible for the youth\rquote s clinical needs?}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 

\b\f1\fs24\insrsid6359864 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 

\af0 \ltrch\fcs0 \insrsid6359864 \trowd \irow12\irowband12\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow13\irowband13\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow14\irowband14\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow15\irowband15\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11022969\charrsid11022969 Who will provide for the youth\rquote s educational needs?}{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 

\b\f1\fs24\insrsid6359864 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 

\af0 \ltrch\fcs0 \insrsid6359864 \trowd \irow16\irowband16\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow17\irowband17\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow18\irowband18\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow19\irowband19\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11022969\charrsid11022969 Who will be responsible for t}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11022969 

he transportation arrangements?}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6359864\charrsid11022969 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 

\af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6359864 \trowd \irow20\irowband20\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb

\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 

\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 

\f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {

\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 \trowd \irow21\irowband21\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow22\irowband22\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow23\irowband23\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\trowd \irow24\irowband24\ltrrow\ts22\trgaph108\trrh278\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 

\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid11022969 

\rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11022969\charrsid11022969 What local 

community services have been involved in this plan and how? Please identify them and any details}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid2033880 . i.e.}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11022969\charrsid11022969  }{

\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11022969\charrsid2033880 {\field{\*\fldinst SYMBOL 240 \\f "Symbol" \\s 12}{\fldrslt\f3\fs24}}}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11022969\charrsid11022969  

{\*\xmlopen\xmlns2{\factoidname PlaceName}}{\*\xmlopen\xmlns2{\factoidname place}}Police{\*\xmlclose} }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11022969\charrsid2033880 {\field{\*\fldinst SYMBOL 240 \\f "Symbol" \\s 12}{\fldrslt\f3\fs24}}}{

\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11022969\charrsid11022969  {\*\xmlopen\xmlns2{\factoidname PlaceName}}Fire{\*\xmlclose} }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11022969\charrsid2033880 {\field{\*\fldinst SYMBOL

 240 \\f "Symbol" \\s 12}{\fldrslt\f3\fs24}}}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11022969\charrsid11022969  {\*\xmlopen\xmlns2{\factoidname PlaceName}}Ambulance{\*\xmlclose} }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid11022969\charrsid2033880 {\field{\*\fldinst SYMBOL 240 \\f "Symbol" \\s 12}{\fldrslt\f3\fs24}}}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11022969\charrsid11022969  {\*\xmlopen\xmlns2{\factoidname PlaceType}}Hospital

{\*\xmlclose}{\*\xmlclose} }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid11022969\charrsid2033880 {\field{\*\fldinst SYMBOL 240 \\f "Symbol" \\s 12}{\fldrslt\f3\fs24}}}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid11022969\charrsid11022969  Other}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6359864\charrsid2033880 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 

\rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6359864 \trowd \irow24\irowband24\ltrrow\ts22\trgaph108\trrh278\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl

\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\trowd \irow25\irowband25\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh

\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl

\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 

\af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow25\irowband25\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow26\irowband26\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid6359864 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \f1\fs28\insrsid6581125\charrsid6581125 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6581125 

\trowd \irow27\irowband27\lastrow \ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 

\b\f1\insrsid1659336 

\par }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid6108698\charrsid7880916 

\par }\pard \ltrpar\ql \fi-720\li720\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin720\itap0\pararsid5902024 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5902024 *\tab 

If the discharge responsibility is not the applicant please provide signed letter from that party indicating their acknowledgment of this responsibility.  }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6622801\charrsid5902024 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6622801 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid5902024 

\par 

\par }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid7041238 

\par 

\par }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid5902024 

\par }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid1659336\charrsid6622801 FINANCIAL RESPONSIBILITY}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\lang1033\langfe1033\langnp1033\insrsid1659336\charrsid6622801 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid7880916 

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid7880916 While food, shelter and program costs are the responsibility of the centre other costs are the responsibility of the resident\rquote s Parent/Guardian unless negotiated otherwise. 



\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\fs24\insrsid1659336\charrsid7880916 

\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trrh289\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3798\clshdrawnil \cellx3690\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7218\clshdrawnil \cellx10908

\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid15286767 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\b\f1\fs24\insrsid7563038\charrsid7563038 Costs cover}{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\fs24\insrsid7563038 ed by the Secure {\*\xmlopen\xmlns2{\factoidname PersonName}}Treatment{\*\xmlclose} Program}{\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\fs24\insrsid7563038 \cell }\pard \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 {\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\fs24\insrsid7563038\charrsid7563038 Costs covered by the Parent/Guardian

\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 

\insrsid7563038 \trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trrh289\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3798\clshdrawnil \cellx3690\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7218\clshdrawnil \cellx10908\row \ltrrow

}\trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3798\clshdrawnil \cellx3690\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7218\clshdrawnil \cellx10908

\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\fs24\insrsid7563038\charrsid7880916 Basic clothing maintenance}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7563038 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7563038\charrsid7880916 Clothing suitable for the resident\rquote }{\rtlch\fcs1 

\af1 \ltrch\fcs0 \f1\fs24\insrsid7563038 s age, sex, weather and program\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7563038 \trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3798\clshdrawnil \cellx3690\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth7218\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7563038\charrsid7880916 Personal care supplies}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7563038 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\fs24\insrsid7563038\charrsid7880916 Any extraordinar}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7563038 y costs such as special therapy\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 

\rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7563038 \trowd \irow2\irowband2\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl

\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3798\clshdrawnil \cellx3690\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7218\clshdrawnil \cellx10908\row \ltrrow

}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\fs24\insrsid7563038\charrsid7880916 Basic school supplies}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7563038 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid14502435\charrsid7880916 

Long distance transportation, beyond 100 km round trip from Syl Apps, including the staffing costs}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7563038 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7563038 

\trowd \irow3\irowband3\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3798\clshdrawnil \cellx3690\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7218\clshdrawnil \cellx10908\row \ltrrow

}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\fs24\insrsid7563038 A}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7563038\charrsid7880916 llowance of up to $5 per week}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7563038 \cell }{\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\fs24\insrsid15286767\charrsid7880916 Medical, including prescription medication, optometrist}{\rtlch\fcs1 \af1 \ltrch\fcs0 \f1\fs24\insrsid7563038 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7563038 

\trowd \irow4\irowband4\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3798\clshdrawnil \cellx3690\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7218\clshdrawnil \cellx10908\row \ltrrow

}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1 \ltrch\fcs0 

\f1\fs24\insrsid7563038 \cell }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid15286767\charrsid15286767 Dental, beyond regular check ups}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid7563038\charrsid15286767 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid7563038 

\trowd \irow5\irowband5\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3798\clshdrawnil \cellx3690\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth7218\clshdrawnil \cellx10908\row \ltrrow

}\trowd \irow6\irowband6\ltrrow\ts22\trgaph108\trrh220\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11283654\charrsid6622801 C}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid13318647\charrsid6622801 ontact person\rquote 

s name and phone number }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11283654\charrsid6622801  for medical and dental billing:}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid11283654 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid2769356\charrsid12263304 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid11283654 \trowd \irow6\irowband6\ltrrow\ts22\trgaph108\trrh220\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\trowd \irow7\irowband7\ltrrow\ts22\trgaph108\trrh340\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl

\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6622801 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6622801\charrsid6622801 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6622801 \trowd \irow7\irowband7\ltrrow\ts22\trgaph108\trrh340\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\trowd \irow8\irowband8\ltrrow\ts22\trgaph108\trrh220\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl

\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6622801 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6622801\charrsid6622801 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid6622801 \trowd \irow8\irowband8\ltrrow\ts22\trgaph108\trrh220\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\trowd \irow9\irowband9\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl

\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid15286767\charrsid12263304 If there are any 

concerns in regard to any of the financial responsibilities please indicate them with potential solutions.}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid15286767\charrsid12263304 \cell }\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid15286767 

\trowd \irow9\irowband9\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 

\ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6622801 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6622801\charrsid6622801 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12263304 \trowd \irow10\irowband10\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid8404052 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6622801\charrsid6622801 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12263304 \trowd \irow11\irowband11\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid8404052 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6622801\charrsid6622801 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12263304 \trowd \irow12\irowband12\ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row \ltrrow}\pard\plain \ltrpar

\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid7880916 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\b\f1\fs24\insrsid8404052 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid6622801\charrsid6622801 \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid12263304 \trowd \irow13\irowband13\lastrow \ltrrow\ts22\trgaph108\trrh287\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr

\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt

\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth11016\clshdrawnil \cellx10908\row }\pard \ltrpar

\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid1659336\charrsid7880916 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid5710507 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid6622801 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid8347977 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid8347977 SINGNIFICANT OTHERS

\par }{\rtlch\fcs1 \af1 \ltrch\fcs0 \b\f1\ul\insrsid8347977\charrsid8347977 

\par \ltrrow}\trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3168\clshdrawnil \cellx3060\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3060\clshdrawnil \cellx6120\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4932\clshdrawnil \cellx11052\pard\plain \ltrpar

\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8347977 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 

\b\f1\fs28\insrsid8347977 Name\cell Relationship\cell Address/Telephone\cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 

\fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 \insrsid8347977 \trowd \irow0\irowband0\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 

\trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 \trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 

\clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3168\clshdrawnil \cellx3060\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 

\cltxlrtb\clftsWidth3\clwWidth3060\clshdrawnil \cellx6120\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4932\clshdrawnil \cellx11052\row \ltrrow}\pard\plain \ltrpar

\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8347977 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 

\b\f1\fs28\insrsid8347977 

\par \cell \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 

\insrsid8347977 \trowd \irow1\irowband1\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3168\clshdrawnil \cellx3060\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3060\clshdrawnil \cellx6120\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4932\clshdrawnil \cellx11052\row \ltrrow}\pard\plain \ltrpar

\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8347977 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 

\b\f1\fs28\insrsid8347977 

\par \cell \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 

\insrsid8347977 \trowd \irow2\irowband2\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3168\clshdrawnil \cellx3060\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3060\clshdrawnil \cellx6120\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4932\clshdrawnil \cellx11052\row \ltrrow}\pard\plain \ltrpar

\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8347977 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 

\b\f1\fs28\insrsid8347977 

\par \cell \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 

\insrsid8347977 \trowd \irow3\irowband3\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3168\clshdrawnil \cellx3060\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3060\clshdrawnil \cellx6120\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4932\clshdrawnil \cellx11052\row \ltrrow}\pard\plain \ltrpar

\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8347977 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 

\b\f1\fs28\insrsid6108698 \cell 

\par \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 

\insrsid6108698 \trowd \irow4\irowband4\ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3168\clshdrawnil \cellx3060\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3060\clshdrawnil \cellx6120\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4932\clshdrawnil \cellx11052\row \ltrrow}\pard\plain \ltrpar

\qc \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\pararsid8347977 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 

\b\f1\fs28\insrsid6108698 

\par \cell \cell \cell }\pard\plain \ltrpar\ql \li0\ri0\widctlpar\intbl\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0 \rtlch\fcs1 \af0\afs20\alang1025 \ltrch\fcs0 \fs20\lang4105\langfe1033\cgrid\langnp4105\langfenp1033 {\rtlch\fcs1 \af0 \ltrch\fcs0 

\insrsid6108698 \trowd \irow5\irowband5\lastrow \ltrrow\ts22\trgaph108\trleft-108\trbrdrt\brdrs\brdrw10 \trbrdrl\brdrs\brdrw10 \trbrdrb\brdrs\brdrw10 \trbrdrr\brdrs\brdrw10 \trbrdrh\brdrs\brdrw10 \trbrdrv\brdrs\brdrw10 

\trftsWidth1\trftsWidthB3\trautofit1\trpaddl108\trpaddr108\trpaddfl3\trpaddft3\trpaddfb3\trpaddfr3\tbllkhdrrows\tbllklastrow\tbllkhdrcols\tbllklastcol\tblind0\tblindtype3 \clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 

\clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3168\clshdrawnil \cellx3060\clvertalt\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth3060\clshdrawnil \cellx6120\clvertalt

\clbrdrt\brdrs\brdrw10 \clbrdrl\brdrs\brdrw10 \clbrdrb\brdrs\brdrw10 \clbrdrr\brdrs\brdrw10 \cltxlrtb\clftsWidth3\clwWidth4932\clshdrawnil \cellx11052\row }\pard \ltrpar\qc \li0\ri0\widctlpar\brdrb\brdrs\brdrw30\brsp20 

\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid2769356 {\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \b\f1\fs32\insrsid7041238 

\par 

\par 

\par }{\rtlch\fcs1 \af1\afs32 \ltrch\fcs0 \b\f1\fs32\insrsid2769356 PART 3

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid5710507 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid2769356\charrsid11082530 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid5902024 {\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid16471626\charrsid6108698 HEALTH CARE / }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 

\b\f1\fs28\ul\insrsid15598371 MEDI}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid16471626\charrsid6108698 CAL INFORMATION}{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid12086670\charrsid6108698 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid5710507 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid3234517 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5902024 Doctor\rquote s Name:  __________________     Telephone:  ______________     Date Last Seen:  _____

\par }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid5902024\charrsid5902024  }{\rtlch\fcs1 \af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid5902024 

\par }{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5902024 Dentist\rquote s Name:  __________________     Telephone:  ______________     Date Last Seen:  _____}{\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5902024\charrsid5902024 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid7617615 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4328656 Health Card #:  ____________________     Health/Drug Insurance Co.:  ______________________

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid4328656 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4328656 Height:  ________     Weight:  ________     Aids Required:  ________________________________}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4328656\charrsid4328656 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4328656 

\par Allergies:  ________________________________________________________________________

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid4328656 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4328656 Diversity Considerations }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid4328656 (cultural, dietary, language etc.)}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4328656 

:  ___________________________________}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4328656\charrsid4328656 

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid4328656\charrsid4328656 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5902024 Significant Medical Issues }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid5902024 (include history, }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid4328656 

surgeries, family history, test results etc.)}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4328656 :}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid5902024 

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid4328656 ______________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

\par 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid9773039 Current Medication: }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid9773039 _______________________________________________________

\par ______________________________________________________________________

\par 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid9773039 Additional Medical Information:  }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid9773039 ______________________________________________

\par ______________________________________________________________________}{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid9773039\charrsid9773039 

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid4328656 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3034264 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid6108698 

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid3034264 SCHOOL INFORMATION

\par 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3034264 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid3034264 School Name

:  ____________________________     Last Grade Completed:  ________________

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid3034264 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid3034264 Contact Name:  ___________________________     Telephone:  __________________________

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid3034264 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3034264 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid6108698 

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\ul\insrsid3034264 LEGAL INFORMATION

\par 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3034264 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid3034264 Lawyer }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid3034264 

(Family Court)}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid3034264 :  _______________________     Telephone:  ________________________

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid3034264 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid3034264 Location for Initial Application and Future Extensions:  _______________________________

\par 

\par 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid7041238 

\par 

\par 

\par 

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\brdrb\brdrs\brdrw30\brsp20 \wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3034264 {\rtlch\fcs1 \ab\af1\afs32 \ltrch\fcs0 \b\f1\fs32\insrsid3034264 PART 4

\par }\pard \ltrpar\qc \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid3034264 {\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid3034264 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid10509478 {\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid10509478 What strengths does the child possess?  }{\rtlch\fcs1 \ab\af1\afs28 

\ltrch\fcs0 \b\f1\fs28\insrsid10509478 _______________________________________}{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid3034264 

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid10509478 

__________________________________________________________________________________________________________________________________________________________________________________________________________________

\par 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid10509478 What goal}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4541131 s would you like to see achieved?  }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid4541131 

_____________________________________}{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid10509478 

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid4541131 

__________________________________________________________________________________________________________________________________________________________________________________________________________________

\par 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \b\f1\fs24\insrsid4541131 Briefly describe strategies that have been successful, unsuccessful and triggers for the child?

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid4541131 ________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________

\par }{\rtlch\fcs1 \ab\af1\afs28 \ltrch\fcs0 \b\f1\fs28\insrsid4541131\charrsid4541131 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid7880916 {\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid8942219 

\par }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid6108698 

\par 

\par }{\rtlch\fcs1 \ab\af1 \ltrch\fcs0 \b\f1\insrsid6108698\charrsid7880916 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid6952697 _____________________________}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6952697 _\tab ________________________}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336\charrsid6952697  \tab __________________

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6952697 Name (Please Print) \tab \tab \tab Signature\tab \tab \tab \tab }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid1659336\charrsid6952697 Date}{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 

\f1\fs24\insrsid1659336 

\par }{\rtlch\fcs1 \ab\af1\afs24 \ltrch\fcs0 \f1\fs24\insrsid6581125 

\par }\pard \ltrpar\ql \li0\ri0\widctlpar\wrapdefault\aspalpha\aspnum\faauto\adjustright\rin0\lin0\itap0\pararsid6581125 {\rtlch\fcs1 \af1\afs24 \ltrch\fcs0 \b\f1\fs24\ul\insrsid6581125 

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