Texas Partner Application

Targeted Characteristics (con't)

Check all that apply

Maladaptive Behaviors

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Medically Fragile

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Intellectual Disabilities

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Oppositional Defiant

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Pervasive Developmental Disorder

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Physically Abused

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Physically Neglected

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Pregnant

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Primary Medical Needs

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Probation/Parole/TYC/JPC

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Requires Hospitalization

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Runaway History

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Sexual Abuse History

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Sexually Inappropriate / Sexualized Behaviors

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Sexual Perpetrator History

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Special Needs

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Substance Abuse / Use

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Substance Abuse or Dependence with the need for medical detoxification

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Suicidal

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Suicidal Gestures

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Suicidal Ideation

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Verbal Aggression
Threaten, bully or other coercing, including threats of physical harm

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Other

Does applicant currently serve children with this characteristic?

Yes
No

If DFPS needed to place a child with this characteristic, would the child be accepted?

Yes
No

If the answer is NO, and the child later exhibited this characteristic, would the child be discharged?

Yes
No

Agency Details

List Other Applicable Site Locations

Leadership

Chief Agency Executive

Program Administrator

Agency Audit Contact

Chief Financial Contact

Agency Information

Partnership

Agency Review

Licensure/Accreditation/Certification

Affiliations

Quality Review

Has your facility had:

Financial Review

Residential Facilities

Service Types

Treatment Services for Children with

Placement Services/Levels of Care

Targeted Characteristics

Targeted Characteristics (con't)