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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.




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




















































Biological Parents Information


Mother










Father











Other Parent/Guardian Demographics














































Additional Family Information

Siblings: Please list all siblings, including step and half sibling

Name Age Sex Residence


Family Of Origin History

(Check all that apply)


Present During Childhood
Mother
Father
Stepmother
Stepfather
Brother(s)
Sister(s)
Other
Parents' current marital status

Describe childhood family experience

Biological mother and her side of family

Biological Father and his side of family

Biological sibling's history


Emergency Information

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


First Name:
Last Name:
Relationship:
Email:
Home Phone:
Work Phone:
Cell Phone:
First Name:
Last Name:
Relationship:
Email:
Home Phone:
Work Phone:
Cell Phone:

Primary Insurance Information

Primary Insured Name (first/last):
Social Security #:
Date of Birth:
Relationship:
Mailing Address:
City:
State:
Zip:
Phone Number:
Employer:
Insurance Company:
Phone Number:
Policy ID:
Group ID:

Secondary Insurance Information

Primary Insured Name (first/last):
Social Security #:
Date of Birth:
Relationship:
Mailing Address:
City:
State:
Zip:
Phone Number:
Employer:
Insurance Company:
Phone Number:
Policy ID:
Group ID:


Placement over the last year

Current Locations Patient Has Been In Over The Last Year Admit Date Discharge Date Reason for Going to Another Facility
Hospital
Inpatient Psychiatric Facility
Incarcerated
Residential Treatment Center
Group Home
Boarding School
Other

Please Describe Other Location:


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.


Current Psychiatric Diagnosis(s) (Include Documentation to Prove):


List Current Medications Name, Dosage and Frequency She is Taking:


What do you think are the precipitating factors to this current crisis?


Describe and personal loss that she has experienced:


Describe any past physical, emotional or sexual abuse, neglect or exploitation that she has experienced (what age, by whom, duration):


Describe anything that has impeded her previous treatment(s) or intervention(s) in your opinion:


List her strengths:


List her weaknesses:


What does she do for leisure and recreational activities?


Does she have any legal issues (probation, court-ordered treatment, felony/misdemeanor charges, convictions)?


Does she have any physical limitations? Is she at risk of falling down, if yes explain:


Does she have any nutritional issues and special dietary needs?

Check Those That Apply:

If yes to any above, please explain:


Does she complain of any kind of pain? If so, where does she hurt and what is the intensity on a scale of 1-10 (with 10 being severe)?

What relieves the pain?


What do you think her needs will be on discharge, (ie. new school, on-going family therapy)?

Any family factors that need to be considered for discharge planning?

What do you think are roadblocks to her recovery or treatment?


What are your goals and expectations for her in treatment?


Medial History


Student Past Medical History

(check all that apply)


Describe any serious hospitalizations or accidents:

Other chronic or serious health issues:

Family Past Medical History

(check all that apply)


Describe any serious hospitalizations or accidents:

Other chronic or serious health issues:


Explain in detail any areas checkmarked or identified above:

Include details of illness, date occurred, date resolved and details of outcome.


Current Mental Health and Behavioral History

If not taking any mood altering medications type in NONE


History of Inpatient/Outpatient Therapy

Prior Provider Name Inpatient/ Outpatient City State Diagnosis Intervention Modality Date Treatment Started Date Treatment Ended Beneficial Yes/No

Disconinued Medications

List any medications that she has TRIED to control her moods and behaviors

Medication Reason Taking Medication Date Medication Started Date Medication Ended Reason Medication Discontinued

Student Social History

(Check all that apply)


Social Support System


Legal History



Total time served:

Descride Last Legal Difficulty:
Employment


Sexual History

Age first pregnancy:
Age first sex experience:
Additional information:
Cultural/Spiritual/Recreational History
Describe any cultural issues that contribute to current problem:

Currently active in community/recreational activities?

Formerly active in community/recreational activities?

Currently engaged in hobbies?

Currently participate in spiritual activities?

History Family Relationships

(When completing this form Step Family is also Adoptive Family)


Describe her relationship with her bio-father

Describe her relationship with her bio-mother

Describe her relationship with her bio-siblings

Describe bio-family's strengths

Describe bio-family's weaknesses

Describe student's strengths

Describe her relationship with her step-father

Describe her relationship with her step-mother

Describe her relationship with her step-siblings

Describe step family's strengths

Describe step family's weaknesses

Describe student's weaknesses

Describe any other support systems for the student (i.e. grandparents, uncles, aunts etc.)

Hygiene



Psychological History

Has she had a psychological evaluation?

If yes, attach

Mood Issues: Does she exhibit signs of anxiety, depression, mood swings, etc? If yes, describe:

Obsessions/Compulsions: Does she exhibit recurrent thoughts of repeated behaviors that she cannot control? If yes, describe:

Anger: Describe the ways she expresses anger:

Unusual Behaviors: Describe the ways she expresses anger:

Isolation: Does she have problems with isolation? If yes, describe:

Describe major events that she has struggled with (divorce, death, moving, birth of sibling, etc)


Student Developmental History

(check all that apply)


Problems During Mother's Pregnancy


If other, describe:


Birth


Describe:

Birth weight, lbs, oz:


Infancy



Childhood Health


Designate the age of when she suffered from these illnesses as well as any allergies and significant injuries.


Delayed developmental milestones

(check only those milestones that did not occur at expected age)


Describe Other:


Intellectual/Academic Functioning

(check all that apply)

Social Interaction

(check all that apply)

describe other:

Childhood Emotional Behavioral Problems

(Behavior 0-11 years of age, check all that apply)

describe other:


Educational History


Current Grade:

GPA:

Last Grade Completed:

Favorite Subject:

Least Favorite Subject:

Name of school:

Address:

Phone:

Describe Academic Performance:

Grade School:

Middle School:

High School:

Describe Difficulties in School:

Describe Special Education Needs:


Sexual Risk Assessment


Is she sexually active?

What is her sexual orientation?

Does she have multiple partners? If yes, explain:

Does she indulge in risky sexual activity (unprotected sex, with strangers? If yes, explain:

Is she addicted to sex? If yes, explain:

Is she a sexual perpetrator or solicits sex? If yes, explain:

Does she exhibit sexual deviance (sex with a child, animals)? If yes, explain:

Inappropriate sexual acts of content on the internet or social media? If yes, explain:


Current Symptoms She is Experiencing

Mark ALL that Apply


Mental Status

Mark ALL that Apply


Appearace:

Attitude:

Perceptions:

Thought Process:

Speech:

Affect:

Aggression/Violence Risk Assessment


Is she violent or aggressive with other kids, siblings or property? If yes, explain:

Is she violent or aggressive with parents? If yes, explain:

Is she violent with authority figures? If yes, explain:

Has she ever been expelled from school or another program for aggressive of violent behavior? If yes, explain:

Has she ever been in trouble with law or had law enforcement called due to her aggressive/violent behavior? If yes, explain:

During her violent/angry outbursts what calms her down?

How frequent are her violent/angry outbursts?

Has she had to be restrained to control her behavior? If so, how often?


Suicide Self Harm Risk Assessment


Does she have any self-harm behavior, (cutting, scratching, eating disorder, hair pulling, scab picking)?

Has she ever verbalized or had feelings or thoughts that she didn't want to live?

Has she ever tried to kill or harm herself before?


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

Does she currently feel that she does not want to live?

When was the last time she had thoughts of dying?

Has anything happened recently to make her feel this way?

Does she feel hopeless and/or worthless?

On a scale of 1 to 10 (10 being strongest) how strong is her current desire to kill herself?


Does she have a suicide plan?

Has she made a minimal commitment to NOT harm herself? If yes, explain:

Has she made any suicide attempts? If yes, explain when and how:

Have any of these attempts been considered "attention seeking behavior" by professionals?


Homicidal Risk Assessment


Has she ever had feelings or thoughts that she wanted to harm others?


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

Has she ever tried to kill or harm anyone before?


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

Is she currently threatening to harm others? If so, who?

When was the last time she had thoughts of hurting others?

Has anything happened recently to make her feel this way?

In what ways does she threaten to harm others?


Cognitive Ability


What age do you think she is emotionally?

What age do you think she is intellectually?

What grade is she in?

What grade should she be in?

Describe any learning disabilities she has:

Describe her ability to communicate with others:

Describe her ability to understand her environment:

What is her IQ?


Family Relationship


Does she make friends easily?

With what kind of friends does she spend her time?

Any gang affiliations?

Is she bullied?

Does she run away?

If she runs away, where does she go?

How long is she gone for when she runs away?

Does she leave the house even though she has been told she can't?

Has she runaway and the police had to get involved? If yes, explain:


Does she misuse social media? If yes, explain:


Patient Substance Abuse History


Substance Used How Used Age Of 1st Use How Long Used Freq Date Of Last Use List Anyone Biologically Related To Patient Who Uses Or Used This Substance
Methamphetamine
Cocaine
Heroin
LSD/Hallucinaogens
Marijuana
Painkillers (Not As Prescribed)
Stimulants
Methadone
Tranquilizers/Sleeping Pills
Alcohol
Ecstasy
Cigarettes/Pipe/Cigars/E-cigs
Caffeinated Beverages
Other

Explain Other:


What are your specific goals for treatment?

I, , am the to 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.

Signature (filling in your name represents your legal signature and will be treated as such):

Date:

Email: