Pre-Screening Admission Form
Please provide relevant information to help us assess suitability for residential treatment.
1. Basic Child Information
Child's Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Current City/State
*
Current Placement/Location
*
Please Select
Home
Hospital/ED
Psychiatric Inpatient
Residential Facility
Foster Care
Other
2. Parent/Guardian Information
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
*
example@example.com
3. Referral Source Information
Referral Source
*
Please Select
Hospital
CMH
School
Residential Program
Physician
Therapist
Friend/Family member
Internet Search
Other
Referral Organization Name
*
Case Worker/Referral Name
*
Role/Title
*
Contact Phone and Email
*
Diagnostic/Clinical Information
Current Diagnoses (ASD and related)
*
Autism Spectrum Disorder (ASD)
Attention Deficit Hyperactivity Disorder (ADHD)
Intellectual Disability
Anxiety Disorder
Mood Disorder
Post Traumatic Stress Disorder (PTSD)
Disruptive Mood Dysregulation Disorder (DMDD)
Oppositional Defiant Disorder (ODD)
Obsessive Compulsive Disorder (OCD)
Psychosis
Other
Verbal Ability
*
Verbal
Minimally Verbal
Nonverbal
Cognitive Functioning
*
Average
Mild Intellectual Disability (IQ 50–70)
Moderate Intellectual Disability (IQ 35-50)
Severe Intellectual Disability (IQ 20-35)
Unknown
4. Current Behavior/Safety Concerns
Current Behaviors/Safety Concerns
*
Aggression toward others
Self-Injury
Elopement
Property destruction
Sexualized behaviors
Suicidal ideations/statements/attempts
Setting fires
Pica
Severe dysregulation
School refusal
Physical restraint history
Police involvement history
Psychiatric hospitalization history
None
Other
If yes, please describe frequency, severity, most recent incident
*
5. Current Services/Supports
Current Services:
*
ABA services
Psychiatry/medication management
Therapy/Counseling
Special education supports
IEP
BIP
Wrap around services
Case management
None
Other
If yes, please describe level of success/helpfulness (improvements made, some progress, no progress, regression).
*
History
*
Emergency room visits
Inpatient psychiatric hospitalization
Residential treatment
Juvenile detention
None
If yes, please provide dates, facility names, and number of admissions
*
6. Medical Information
Current or history of:
*
Seizures
Mobility concers/wheelchair
Feeding concerns/GI tube
Injectable medication
Severe allergies
Colostomy bag
None
Other
If yes, please share any additional information
*
Current medications (name, dose, frequency):
*
7. Insurance Information
Primary Insurance
*
Secondary Insurance
Medicaid/CMH
Other coverage/benefits/waivers
Please upload front of insurance card
*
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Please upload back of insurance card
*
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Additional Information
Please provide any additional information
*
Upload any supporting documents (psychiatric evaluations, clinical notes, discharge summaries, IEP, BIP, etc)
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Consent/Disclaimer
Type a question
*
I understand that submitting this form does not guarantee admission
I understand that information submitted in this form is confidential and reviewed by our admission team
I consent to being contacted regarding this submission
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