CTS Wilderness Intake Form
Wilderness programs combine therapy and skill building through experiences in an outdoor environment to kinetically engage clients on cognitive, affective, and behavioral levels to create long term changes, create positive relationships, and increase self-worth.
Youth Information
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Full Name
Date of Birth (MM/DD/YYYY)
Medicaid #
Parental/Guardian Information
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Full Name
Phone number
Email Address
Physical Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Referring Agency and Primary Contact
Primary MH Therapist/School Counselor/Caseworker
Name
Phone number
Email Address
Please check below to provide consent for CTS Staff to contact Primary Therapist for understanding of treatment goals and hopes for engaging in Wilderness program
Yes
No
Medical History
Youth's Primary Care Physician and Phone Number
Please describe any medical concerns your child experiences that we should be aware of?
Date of last physical exam
Allergies or sensitivities (include dietary restrictions)
Please list any medications and doses
Are there any behavioral concerns that staff should be aware of when engaging in wilderness program (history of self harm, substance use, suicidal ideation, elopement risk, etc)
If your child were to become upset or triggered, what are coping strategies they use to help calm them down?
Do you have other concerns about your child or your family that you have not mentioned yet?
What do you and your child hope to get out of engaging in an wilderness program?
What are your child’s strengths?
What is your child's experience in the wilderness/outdoors?
Any dietary restrictions or preferences?
We do our best to accommodate the needs of all participants. Having enough energy is a critical part of this trip, please let us know of any allergies or aversions.
Guardian Acknowledgement of Photo Release: I grant permission to Collaborative Trauma Solutions, its agents, and its employees the irrevocable and unrestricted right to produce photographs and video taken of my child while at Collaborative Trauma Solutions Wilderness Retreat for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner or in any medium by Collaborative Trauma Solutions. I hereby release Collaborative Trauma Solutions and its legal representatives from liability for any violation or claims relating to said images or video. I waive my right, my child’s rights, and my family’s rights to any and all compensation stemming from the use of these materials.
Over the Counter Medication Release I grant permission for Collaborative Trauma Solutions to provide Non-prescription medications, or over the counter (OTC) medications (such as acetaminophen, ibuprofen, antacid, Benadryl, and melatonin) may be administered with written permission through a signature below from parents/guardians. All OTC medications will be in the original packaging and given as recommended as on the bottle.
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Please sign if in agreement for Collaborative Trauma Solutions Liability Form
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Our Family Engagement Gathering on April 21st from 1-5pm will provide a welcoming home for our youth with activities and a shared meal. We invite families to attend, including siblings. We want to ensure enough food and age inclusive activities. Please provide the names, ages and any dietary restrictions for all family members.
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