After-Hours Crisis Line for PORT Health Patients 1-866-488-7678

Adolescent Residential Program Form

Are you in crisis?

Patient Information

Past hospitalizations and recent treatment history
(please include both inpatient, outpatient, community based services and reason for referral to level of care)

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.

School History

Referral Information

Contact Information for Referring Agency

Insurance Information

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

Required Items/Documents for Admission

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