Behavioral Health Services Application

CHILDHOOD RELATED TRAUMA
Please note any childhood related trauma that the child has experienced or witnessed

Other
Long Range Treatment Goals for the Child and Family

TREATMENT HISTORY
Please list all therapists, psychologists, psychiatrists and /or mental health professionals who have evaluated or treated the child within the past 2 years. Start with the most recent.
Please upload the Historical Treatment Records (if applicable)

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PLACEMENT HISTORY
Has the child ever been hospitalized or placed in a treatment facility, group home, foster care or other placement?
Leaving Placement Details

HEALTH INSURANCE INFORMATION
Please complete information in this section based on your current insurance coverage to allow FCSA to bill insurance for services rendered. If the child is covered by Medicaid and is also covered by a private health insurance policy, you must list the health insurance information in the space provided below for FCSA to bill. Submitted Applications will not be processed without insurance information. A copy of the child’s Denali Kid Care Card and/or Other Insurance Card must be attached.
Child Name

First NameLast Name
Child Date of Birth

MonthDayYear
- Do you have health insurance?
- Please attach a copy of the child’s Denali Kid Care Card and/or Other Insurance Card must be attached
  
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- Medicaid or Denali Kid Care #
- Coverage Dates (To)
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Coverage Dates (From)
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Insurance Company Name
- Policy Number
- Company Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Policy Start Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Policy End Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Group Name:
- Policy Holder’s Name:
- Policy Holder’s Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Policy Holder’s Social Security Number:
- Policy Holder’s Date of Birth
  
  MonthDayYear
- Policy Holder’s Phone #
  Please enter a valid phone number.Format: (000) 000-0000.
- The State of Alaska requires that FCSA collect the following information:
- Please list your gross annual household income: $
  *If you claim this child as a dependent on your federal income tax return, your income will also be used in determining the child’s Medicaid eligibility. If you do not claim the child as a dependent, only the child’s income will be considered in determining Medicaid eligibility
- Insurance Company Name:
- Policy Number
- Company Address:
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Group Number
- Policy Holder’s Name
- Policy Start Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Policy End Date:
  
  MonthDayYear
  2 digit month, 2 digit day, 4 digit yearDate
- Policy Holder’s Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Policy Holder’s Social Security Number:
- Policy Holder’s Date of Birth
  
  MonthDayYear
- Policy Holder’s Phone #
  Please enter a valid phone number.Format: (000) 000-0000.
- Is there any additional information you would like to add?

Signature
Parent or Guardian Name (please print)

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
NAMES OF PERSON COMPLETING THIS APPLICATION (must be from a legal guardian)
Should be Empty:

Rows	Last 6 weeks	History	No History	Describe
Major illnesses/injuries or surgeries
Severe fatigue after little activity
Unusual swelling or lumps
Heart problems in self or family
Blurred vision or difficulty seeing
Buzzing, ringing or infection in ears
Swollen feet or ankles
Persistent colds or coughs
Severe headaches
Problems with your sleep or rest
Bleeding gums or teeth problems
Aching joints or muscles
Constipation or diarrhea
Recent changes in your weight
Any problem with urination
Blood in your stool or urine
Asthma or other respiratory problems
Vomiting more than 3 times per week
Mouth sores more than 3 times per week
Seizures or epilepsy
Diabetes
Tuberculosis
IV Drug Use
HIV+
Pregnant
Any unusual vaginal discharge
Excessive menstrual bleeding

Application for Behavioral Health Services

CHILD’S INFORMATION

If you are not the sole legal guardian, what is the name and contact information of the other guardian/parent?

REASON FOR APPLICATION AND SUPPORTING INFORMATION

CHILDHOOD RELATED TRAUMA

CUSTODY AND LIVING ARRANGEMENTS

SCHOOL STATUS

TREATMENT HISTORY

PLACEMENT HISTORY

MEDICAL INFORMATION

HEALTH INSURANCE INFORMATION

Signature