Admission Application

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    Complete this behavioral health history as detailed as possible. This document is used to complete a prior authorization with your insurance company for treatment at Trinity Teen Solutions. Your insurance will want to ensure that your daughter meets medical necessity for inpatient treatment. An incomplete, inaccurate or minor clinical history will delay the admission process with your insurance company.

    Note: It is possible to save this form and return to finish it at a later date. Simply scroll to the bottom and hit "save and continue later."

  • IN ORDER TO BE CONSIDERED FOR TREATMENT

    PAST CLINICAL RECORDS FROM MENTAL HEALTH TREATMENTS NEED TO BE SUBMITTED FOR CONSIDERATION BY OUR TRATMENT TEAM


    PRIOR TO ADMISSION NEED TO SUBMIT

    1. History and/or physical no older than 30 days before admission date
    2. Unoffical school transcript
    3. Current immunization record

  • Nickname, Preferred Name
  • First Parent/Guardian

  • (first/middle/last)
  • Second Parent/Guardian

  • Biological Mother

  • Biological Father

  • Other Parent/Guardian Information #1

  • Other Parent Or Guardian #2

  • Additional Family Information

  • Include: Name, Age, Sex, Residence
  • Family Of Origin History

    (Check All That Apply)
  • Present During Childhood
  • Emergency Information

    Whom would you like us to contact if we cannot get a hold of parents
  • First Contact

  • Second Contact

  • Primary Insurance Information

  • Secondary Insurance Information

  • Include current locations the patient has been in the last year, admit date, discharge date, & reason for going to another facility
  • PATIENTS WILL BE ADMITTED TO THE BEHAVIORAL HEALTH UNIT WHEN HER BEHAVIORAL HEALTH NEEDS MEET DIAGNOSTIC CRITERIA AND ARE APPROPRIATE FOR DIAGNOSIS AND TREATMENT IN AN INPATIENT RESIDENTIAL TREATMENT CENTER, PARTIAL HOSPITALIZATION PROGRAM AND/OR AN INTENSE OUTPATIENT PROGRAM. IN ORDER TO MEET MEDICAL NECESSITY FOR INSURANCE PURPOSES, YOU NEED TO EXPLAIN IN DETAIL HER BEHAVIORS AS ACCURATELY AS POSSIBLE. MINIMAL INFORMATION WILL HINDER INSURANCE REIMBURSEMENT FOR TREATMENT AND ACCEPTANCE INTO TRINITY TEEN SOLUTIONS.
  • Name, Dosage, and Frequency She is taking
  • Medical History

  • Check All That Apply
  • Check All That Apply
  • Include details of illness, date occurred, date resolved and details of outcome.
  • Current Mental Health and Behavioral History

  • Include the prior provider name, specify if it was inpatient or outpatient, include the city & state, the diagnosis, the intervention modality used, the treatment start & end date, and wheather the treatment was beneficial.
  • List any medications that she has TRIED to control her moods and behaviors including the reason for taking medication, the date started & ended, and the reason she stopped taking it.
  • Student Social History

    Check All That Apply
  • Cultural/Spiritual/Recreational History

  • History Family Relationships

    (When completing this form Step Family is also Adoptive Family)
  • (i.e. grandparents, uncles, aunts etc.)
  • Psychological History

    If yes, upload.
  • Student Developmental History

    Check All That Apply
    (check only those milestones that did not occur at expected age)
    (Behavior 0-11 years of age, check all that apply)
  • Educational History

  • Sexual Risk Assessment

  • Mental Status

    Mark All That Apply
  • Aggression/Violence Risk Assessment

  • Suicide Self Harm Risk Assessment

    If yes, please answer the following, if not skip to the next section.
  • Homicidal Risk Assessment

    If yes, please answer the following, if not skip to the next section.
    If yes, please answer the following, if not skip to the next section.
  • Cognitive Ability

  • Family Relationship

  • Patient Substance Abuse History

  • Include the Substance, how it was used, age of 1st use, how long it was used, frequency of use, date of last use, and list anyone biologically related who uses or used the substance
  • I,

  • am the
  • to the patient, attest that the information provided is complete and accurate. No information was omitted or exaggerated in an effort to obtain treatment for the patient. I/We agree that the information submitted by the Parent/Guardian represents and warrants to TTS that all the information submitted to TTS in connection with the enrollment of the student is true, accurate, complete, and states all information which should reasonably be known by TTS to operate the Program for the benefit of the Student and others. The accuracy and completeness of the information provided by the Parent is a material inducement to TTS's enrollment of the Student in the Program. Failure to provide accurate and complete information shall be a material breach of this Agreement, and TTS shall have the right thereafter to terminate this Agreement.