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PORT Residential

Adolescent Residential Program Form

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1-866-488-7678

Date of referral *

Date teen available for admission *

Patient Information

Person served full name and preferred name (if applicable) *

Date of birth *

Gender *

Male

Female

Parent/guardian name *

Contact phone numbers for parent/guardian *

Address of teen (if teen is placed outside of home, please indicate and explain in comment section) *

Address of parent/guardian (if different from teen) *

Reason for referral and presenting problem *

General statement about challenges the teen is experiencing with family, school, home, or legal *

Diagnosis *

Past hospitalizations and recent treatment history

(please include both inpatient, outpatient, community based services and reason for referral to level of care)

Place and date of service

Type of service

Reason for admission

Comments regarding completion and/or effectiveness

Place and date of service

Type of service

Reason for admission

Comments regarding completion and/or effectiveness

Place and date of service

Type of service

Reason for admission

Comments regarding completion and/or effectiveness

Place and date of service

Type of service

Reason for admission

Comments regarding completion and/or effectiveness

Place and date of service

Type of service

Reason for admission

Comments regarding completion and/or effectiveness

Please list any medical conditions, allergies, or current medication taken by the teen *

A minimal 30-day supply of medications must be provided by the family at time of admission or the teen may not be admitted to the program.

Legal History

Teen is on probation *

Yes

No

if yes

Adult

Juvenile

Name of court counselor(s)

Contact number for court counselor

Current pending charges

Court dates that will occur while teen is in treatment at PORT Health

School History

Is teen currently enrolled in school? *

Yes

No

Name of school

IEP or 504 *

IEP or 504 plan currently

IEP or 504 plan in the past

No IEP or 504

Referral Information

Referring Agency/Person *

Address *

Contact Information for Referring Agency

Phone *

Email *

Insurance Information

Insurance Provider *

Policy Number *

Copy of insurance card must be presented at time of screening, however you may attach a copy to the referral form as well.

Copy of insurance card is attached *

Yes

No

Required Items/Documents for Admission

Required Items/Documents for Admission *

TB Skin Test and record of physical exam (required at admission)

Insurance Card

Documents to support past treatment history

Any pertinent court documents

Evidence of a 504 or IEP (if applicable)

Medical history for pre-existing medical conditions

Documents to Upload

Drag 'n Drop your files here!

Signature of Referring Person *

Date *