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Person Completing This Form

First Name

Middle Name

Last Name

Phone Number

Email Address

Relationship to Child

How did you hear about the Village?

Please select the source.

Through a Child Public Agency / Judicial System

Through a Hospital / Private Practice / Treatment System

Through a Search Engine / Other

Please describe in detail.

Above, please include ...
NAME OF ENTITY (county, hospital, private practice, treatment system, search engine, etc.) ... and
YOUR CONTACT THERE (name, phone number, and email address), if applicable.

Child's Information

First Name

Middle Name

Last Name

Date of Birth

Age

Gender

Child's Address of Residence

City

State

Zip

Why do you feel this child needs residential treatment?

Child's Legal Guardian

Are you the legal guardian?

Yes

Does the child reside with you?

Yes

Contact information for legal guardian, if someone other than you ...

First Name

Middle Name

Last Name

Phone Number

Email Address

Address

City

State

Zip

Insurance Information

Policy Holder Name

Policy Holder Date of Birth

Policy Holder Address

City

State

Zip

Primary Insurance

Insurance Carrier

Group Number

Member ID

Mental Health Services Phone Number

Member Services Phone Number

Secondary Insurance

Secondary Insurance Carrier

Group Number

Member ID

Mental Health Services Phone Number

Member Services Phone Number

Child's School Information

Type of School

Public

Private

Alternative

Homeschool/Homebound

If Public / Private / Alternative school ...

Name of School

Current Grade Level

If the child is currently suspended from school, please explain.

If the child is not in the appropriate grade level, please explain.

Grade Average

Child's IQ, If Known

Does the child have an IEP or 504 plan?

Yes

Please describe current behaviors exhibited during learning times, and the frequency of these behaviors.

Child's Current and Past Treatment Services

PLEASE INCLUDE:
Treatment provider's name, phone number, and email address.
Services provided, service start date, and how many times per week.

Current Treatment

Past Treatment

Child's Legal Involvement

Does the child have any current legal involvement with the judicial system?

County

Probation Officer Name

Phone Number

Email Address

Please describe the legal situation.

Past or Present Petitions

Please include Court Hearing Date, Charge, and Explanation.

Is the child currently in a detention center?

County

Please explain.

Is the child currently in state custody?

County

Case Worker Name

Phone Number

Email Address

Is the child currently facing state custody?

Date of Next Hearing

Child's Health History

What is the current mental health diagnosis (details)?

Any eating disorder concerns (details)?

Irregular sleeping patterns (details)?

Prescription medication (name, dosage, frequency, reason for use, any compliance issues)?

Any type of injections required (details)?

Any allergies – seasonal, foods, medications (details)?

Ever any anaphylactic reaction to any allergens (details)?

Any physical disabilities – prosthetic limbs, broken bones, cast, boot (details)?

History of seizures (details, date of last seizure)?

Any brain or head injuries (date, details)?

Any surgeries (date, details)?

If the child is diabetic ...

Is the child currently on medication for diabetes?

Yes

Is the diabetes controlled by the medication?

Yes

Name of Diabetes Specialist

Phone Number

Date of Last Follow-Up Doctor Appointment

Are there any other health concerns we need to be made aware of before admission?

Substance Abuse

Any alcohol abuse (type of alcohol, date, frequency of use, details)?

Any drug abuse (type of drug, date, frequency of use, details)?

Documents / Records

If you have any recent documents and/or records that may help in the admissions process (for example, recent discharge paperwork or psychological evaluation), please email them to hannah.price@villagebh.com.

Referral Form