Client Information Form

Client Information Form
Student Name:*

First NameMiddle NameLast NameSuffix
Student Date of Birth:*

MonthDayYear
Date
Student Admission Date:*

MonthDayYear
Date
Student Social Security #:
Student Medicaid # (if applicable):
Custody/Guardianship
Custody/Guardianship *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email*
example@example.com
DCF Information (if applicable)
Date of DCF Custody

MonthDayYear
Date
DCF District
DCF District Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DCF District Phone Number

Area CodePhone Number
Insurance Information
Name of Insurance *
Insurance Number*
Medical Information
Medications (Please list name, dose, and time):*
Allergies:*
Height & Weight:*
Known Medical Conditions (If child has a diagnosed medical condition please provide a letter from PCP clearing child for restraints/physical interventions):*
Date of last physical*

MonthDayYear
Date
PCP Name*

First NameLast Name
PCP Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP Phone Number*

Area CodePhone Number
Date of last dental *

MonthDayYear
Date
Dentist Name*

First NameLast Name
Dentist Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Dentist Phone Number*

Area CodePhone Number
Academic Information
Diagnosis prior to admission:*
IEPSection 504 PlanOther
Sending School*
LEA/Supervisory Union Information*
Case Manger Name

First NameLast Name
Grade*
Name(s) of others(s) on the team (ex. Educational Surrogate, Occupational Therapist, Speech/Language Pathologist, counselor, etc)
Please list names and titles/roles of individuals.
Emergency Contact Information

Must be different than already listed individuals.
Individual #1 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Individual #2 Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Family Information
Birth Mother *

First NameLast Name
Birth Mother Status*
Birth Father*

First NameLast Name
Birth Father Status*
Siblings *
List names and ages.
I agree that the management and care of the youth in question, will be under the primary responsibility and management of Brookhaven Treatment and Learning Center.

In signing this consent form, I agree to adhere to the Brookhaven Treatment and Learning Center program policies and procedures (concerning the interview process, intake process, intake, program design, transition and completion) as described in the approved Department of Children and Families contract.
Parent/ Legal Guardian’s Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Client Information Form

Custody/Guardianship

DCF Information (if applicable)

Insurance Information

Medical Information

Academic Information

Emergency Contact Information

Family Information