Residential Services Admission Application


How to use this form:
Use the tab key to move from one text box to another. Don't hit the enter key; you might send the form before you're done. When you finish, click Submit at the bottom.

Patient Information
Name of Child: Last / First / Middle Initial Social Security Number
Sex Race Height Weight Date of Birth

Parent/Legal Guardian Information
Full Legal Name: Last / First / Middle Initial Date Custody Obtained
Email address Telephone Number
Address: Street/City/State/Zip Code
Relationship to Patient Emergency Phone Number

Behavioral Summary
Please provide a summary of the child's current behavior or other issues requiring a residential level of care:
Describe ANY sexually deviant or fire setting behaviors by the child. If a child exhibits any sexually deviant behaviors while in treatment at this facility, the legal guardian will be given a 14-day notice to find an appropriate placement and the resident will be discharged.
Date of last psychological testing
IQ Verbal Performance Full

Treatment History
Please provide a comprehensive summary of past treatment efforts (include acute hospitalizations, outpatient, residential, foster care, group homes, etc.) This section must be completed in full before a decision is made about admission.

To (mm/yy) From (mm/yy) Discharge Plan - Successful? If not, why?
To (mm/yy) From (mm/yy) Discharge Plan - Successful? If not, why?
To (mm/yy) From (mm/yy) Discharge Plan - Successful? If not, why?
To (mm/yy) From (mm/yy) Discharge Plan - Successful? If not, why?
To (mm/yy) From (mm/yy) Discharge Plan - Successful? If not, why?
To (mm/yy) From (mm/yy) Discharge Plan - Successful? If not, why?

Medical History
Please provide the child's current diagnosis and medications

Diagnosis Medications & Dosage

Summary of medical illnesses and issues (both past and present):

Education History
Name, Complete Address and Phone Number of Present School Current Grade


IEP Yes No
List any related services (ie. speech, occupational, etc)
Retention history (if retained, what grade level

Legal History
Please provide the history of legal charges, probation status, probation officer name and phone number.

Treatment Objectives and Issues
Please provide a list of behavioral objectives for this child or adolescent during possible placement

Responsible Party Information
    Same as Parent/Legal Guardian (Parent/Legal Guardian is Responsible Party)
Full Legal Name: Last/First/Middle Initial Social Security Number
Address: Street/City/State/Zip Code Telephone Number
Relationship to Patient Date of Birth

Insurance Policy #1 Information
Insurance Company Name Insurance Co Phone
Address: Street/City/State/Zip Code Group Name
    Same as Responsible Party (Subscriber is Responsible Party)
Subscriber Full Legal Name: Last/First/MI Policy Number
Relationship to Patient Subscriber Date of Birth Subscriber SSN

Insurance Policy #2 Information
Insurance Company Name Insurance Co Phone
Address: Street/City/State/Zip Code Group Name
    Same as Responsible Party (Subscriber is Responsible Party)
Subscriber Full Legal Name: Last/First/MI Policy Number
Relationship to Patient Subscriber Date of Birth Subscriber SSN
 
Discharge Plans
Please provide a summary of your discharge plans upon the child's completion of this program.

Application Referral Information
    Same as Parent/Legal Guardian (Parent/Legal Guardian is Responsible Party)
Submitted By
Company Phone Number
Address: Street/City/State/Zip Code


  

Thank you!