Qualified Individual Request Form

Complete state-sponsored qualified individual (QI) requests with no identifying information and click submit.

1. The date juvenile treatment screening team (JTST) met

2. Confirmation that JTST followed all requirements and processes

Yes

3. Does agency staff have reason to believe child is American Indian?

Yes

a. Is child's tribe/s known?

Yes

b. If yes, identify child's tribe/s

4. Did JTST recommend placement in a qualified residential treatment program (QRTP) certified facility? (QI/QRTP processes are only required when an agency places or plans to place youth in a QRTP certified facility).

Yes

a. Name of QRTP certified facility agency anticipates placing youth

b. Date of anticipated placement in QRTP certified facility

5. Child's current placement setting type and location (city), such as their home, foster home, correctional facility, hospital, or crisis placement in QRTP.

a. If youth was placed in a QRTP certified facility due to a crisis, what date were they placed?

6. For QI requests for out-of-state QRTP placements, confirm that an Inter State Compact on the placement of children (ICPC) agreement was initiated, and the fiscal operations QRTP checklist has been completed and submitted by agency.

Yes

7. Note special requests of a QI, i.e., community, cultural, and/or interpreter needs.

COUNTY OR INITIATIVE TRIBE

County Name Calculated

AGENCY WORKER NAME

EMAIL ADDRESS

PHONE NUMBER