Zen Zone Youth & Wellness Interest Form
This form is used to help determine whether Zen Zone may be an appropriate fit for your child’s behavioral health needs. Completing this form does not guarantee enrollment or services. If your child is experiencing a mental health emergency, active suicidal thoughts, active homicidal thoughts, or immediate danger, please call 911, go to the nearest emergency room, or contact a crisis line immediately.
Internal Vetting Result — For Staff Only
Vetting Decision
Please Select
Good Fit - Schedule Intake
Needs More Information
Refer Out / Higher Level of Care
Insurance Follow-Up Needed
Waitlist
Not Eligible at This Time
Parent/Guardian Information
Name
*
First Name
Last Name
Relationship to Child
*
Please Select
Parent
Guardian
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Preferred contact method
Please Select
Phone
Text
Email
Best time to contact
Please Select
Morning
Afternoon
Evening
Are you the legal guardian?
*
Yes
No
Are there custody concerns or court orders we should be aware of?
*
Yes
No
Child Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Grade
*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
School Name
*
Does the child have an IEP or 504 Plan?
*
Yes
No
Unsure
Current school placement
*
Traditional
Charter
Homeschool
Online
Private
Reason for Interest
What is the main reason you are interested in services for your child?
*
Anger or emotional outbursts
Defiance or difficulty following directions
Trouble with peers
Social skills
Anxiety or excessive worrying
Sadness, withdrawal, or low mood
Trouble focusing or staying on task
School behavior concerns
Suspensions or discipline concerns
Family conflict
Grief/loss
Trauma-related concerns
Bullying
Low self-esteem
Difficulty coping with change
Daily living or routine struggles
Other
Please briefly explain what is happening.
*
How are these concerns affecting your child's daily life?
*
Problems at school
Problems at home
Problems with peers
Difficulty following routines
Frequent emotional outbursts
Trouble completing work
Avoiding school or activities
Suspensions or removals from class
Aggression toward others
Property destruction
Difficulty accepting correction
Trouble using coping skills
Difficulty communicating feelings
Parent/guardian is frequently called by school
Other
How often are these concerns happening?
*
Daily
Several times per week
Weekly
A few times per month
Rarely
Unsure
Safety Screening Questions
Has your child made statements about wanting to harm themselves?
*
Yes
No
Has your child made statements about wanting to harm others?
*
Yes
No
Has your child recently engaged in self-harm?
*
Yes
No
Has your child been physically aggressive toward others?
*
Yes
No
Has your child run away or attempted to run away?
*
Yes
No
Has your child had a recent psychiatric hospitalization?
*
Yes
No
Is there any current safety concern today?
*
Yes
No
Current Services
Is your child currently receiving counseling or therapy?
*
Yes
No
Is your child currently receiving case management, CPST, TBS, or behavioral health services?
*
Yes
No
Unsure
Has your child ever received behavioral health services before?
*
Yes
No
Does your child currently have a diagnosis?
*
Yes
No
Unsure
If yes, what diagnosis?
Is your child taking medication for behavioral or mental health needs?
*
Yes
No
Prefer not to answer
Is your child involved with children services, juvenile court, or probation?
*
Yes
No
Prefer not to answer
Insurance / Payment Screening
Does your child have Medicaid?
*
Yes
No
Unsure
Please select your child’s Medicaid plan, if known.
Please Select
CareSource
Molina
Buckeye
UHC
Anthem
Humana
OhioRISE-Aetna
Unsure
Is your child enrolled in OhioRISE?
*
Yes
No
Unsure
Are you interested in private pay if insurance does not cover services?
Yes
No
Maybe
Can your child participate safely in a group setting?
*
Yes
No
Sometimes
Unsure
Does your child require 1:1 supervision at all times?
*
Yes
No
Sometimes
Unsure
Has your child been suspended or expelled in the last 6 months?
*
Yes
No
Sometimes
Unsure
Does your child have aggressive behaviors that cause injury?
*
Yes
No
Sometimes
Unsure
Is your child able to follow basic directions with support?
*
Yes
No
Sometimes
Unsure
Are you able to participate in treatment planning and sign required forms?
*
Yes
No
Are you willing to attend an intake/assessment appointment?
*
Yes
No
Referral Source
How did you hear about Zen Zone?
Please Select
School
Therapist
Doctor
Friend/family
Facebook/social media
Website
Community event
Medicaid/MCO
Other
Were you referred by someone? If yes, who?
Submit
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