referral form - Shodair Children's Hospital

Shodair Children’s HospitalP.O. Box 5539 Helena, MT 59604 Phone: 800-447-6614 or 406-444-7500 Fax: 406-444-1039Hello ~Enclosed is our residential application. Please feel free to make a copy of theapplication to keep for your files. A copy of the application can also be e-mailedor faxed to you, if needed.This application needs to be filled out completely and legibly, with as muchdetail as possible. The application is usually completed by a parent or the legalguardian. Once completed you may submit this application over the WEB or faxor mail back to us. We are not able to accept applications by e-mail. Please alsogather any supporting documentation to accompany the application, which willgive additional information about the child and why the child needs residentialtreatment. A “Release of Information” form has been included in this applicationto aide in this process of obtaining additional records from treating providers.Our mailing address is: Shodair Children's Hospital, PO Box 5539, Helena, MT,59604. The Admission Department’s fax number is 406-444-1039.Please describe behaviors, etc. on the application. For example: instead of saying"aggressive behaviors" describe what the behaviors are (hitting, biting, kicking,etc.), how frequently they occur, the last time it happened, how long it lasts,who/what the behaviors are aimed at (peers, parents, siblings, teachers, toys,furniture, etc.), known triggers, etc. Our having detailed information from thebeginning speeds up the evaluation process. Once we receive this information wewill evaluate it to see if the child is appropriate for our services and then will getback to you with an answer.If you have any questions or if we can be of further assistance, please call 1-800-447-6614 and ask for the Intake Department.1

SHODAIR RTC ADMISSION ASSESSMENTPatient Name:___ Patient DOB:_____________ Age:______yo Male FemalePatient SS#: _ Is youth emancipated, married or had a child? Yes NoInsurance: Medicaid CHIPS SSI None Private Insurance: _____________________________________________________________(photocopy insurance card or list the policy name, subscriber, policy #, phone #)Patient Living Arrangement: Parents Group Home Foster Home JDC Shelter Other: __________________________Name of Legal Guardian: Hm#) Wk#) Cell#)____________Admission is sought for the following reasons:_____________________________________________________________________________________________________________Assaultive behavior? Yes No Suicidal behavior? Yes No Is patient an eminent danger to self or others? Yes NoPrevious hospitalizations (Where/When): ____________________________________________________________________________Outpatient therapy? □ Yes □ NoTherapist Name: _________________________________________Phone#__________________Start date: ________________ Frequency: Weekly Bi-Monthly Monthly As Needed Modality: Ind. FamilyMental Health Case Manager? □ Yes □ NoName: __________________________________________ Phone#_________________Current Meds/Doses: ____________________________________________________________________________________________Meds prescribed by:________________________________________________General Practitioner _______________________________________________Phone # ___________________________________Phone # __________________________________Victim of Sexual Abuse? □ Yes □ NoHistory of sexual actions with minors? □ Yes □ No __________________________________Need for sex offender treatment? □ Yes □ No Previous sex offender treatment? □ Yes □ No ______________________________Physical health needs? □ Yes □ No Identify: _______________________________________________________________________Cognitive or developmental delays? □ Yes □ No Identify: _____________________________________________________________Legal History?_________________________________________________Name of Probation Officer: ___________________________Drug or Alcohol Use? ____________________________________________ Any Tx. Center? _________________________________Psychiatric Diagnoses Identified: ___________________________________________________________________________________UR/Admissions/Social Hx/RTC: revised Dec 20072

Shodair Child and Adolescent Psychiatric ProgramRTC- Psychosocial and Family AssessmentAdmit Date _____________________________What is the legal status of the patient’s admission to Shodair? VoluntaryCourt OrderMedicalRecordsLabelIDENTIFYING INFORMATIONEthnicity_______________________ Tribe_________________ Birthplace____________________________________Child’s Address: _______________________________________City_______________________ State_____________Zip Code ____________________Child's Phone number: ________________________________Guardian's Address (if not parent & if different than child's)________________________________________________City __________________________ State_________ Zip Code__________ Guardian's Phone #__________________FAMILY HISTORY1) How long were the biological parents together? ______________________Are the parents currently: TOGETHER SEPARATED DIVORCEDIf separated/divorced, when did the separation/divorce take place?___________________2) Have the parents had additional marriages? YES NOIf “YES”, please identify date(s) of marriage(s) and divorce(s): _______________________________________________________________________________________________________________________3) Does the child have contact with both biological parents?: YES NO, why? _________________________________________________________________________________________________4) Is there any information that cannot be disclosed to the patient at this time? NO YES (explain)___________________________________________________________________________________________Is it okay to contact non-custodial parent? Yes NoIf no, explain ____________________________________________________________________________________Biological parents married when child was born? YES NOIf not together, date of parental separation (divorce, breakup, etc.)_____________________________________Name of Biological Father: _____________________________________________________ SS#_______________1. Parental rights terminated? NO YES _____________________________________________________________2. Address_______________________________ City_________________ State_________ ZipCode ____________3. Phone: home#______________________ cell# __________________________ wk#_______________4. Employer______________________________ Occupation___________________________5. Level of Education: Dropped out H.S. Trade Bachelor Master’s PhD/MD Other:____________________6. Mental illness, father or family? NO YES:______________________________________________________________________________________________________________________________________________________7. Substance abuse, father or family ? NO YES: _____________________________________________________3

8. Any Learning disabilities in family? NO YES: __________________________________________________9. Military service history: NO YES: _______________________________________________________________10. Any previous marriages? NO YES: ____________# of kids from previous marriage: _______________________11. How did parent get along with own parents?________________________________________________________Name of Biological Mother: _______________________________________________ SS#_____________________1. Parental rights terminated? NO YES _____________________________________________________________2. Address_______________________________ City_________________ State_________ ZipCode ____________3. Phone: home#______________________ cell# __________________________ wk#_______________4. Employer______________________________ Occupation___________________________5. Level of Education: Dropped out H.S. Trade Bachelor Master’s PhD/MD Other:___________________6. Mental illness, mother or family? NO YES:__________________________________________________________________________________________________________________________________________________________7. Substance abuse, mother or family ? NO YES:_______________________________________________________8. Any Learning disabilities in family? NO YES: ________________________________________________________9. Military service history: NO YES: _________________________________________________________________10. Any previous marriages? NO YES: ____________ # of kids from previous marriage: _______________________11. How did parent get along with own parents?_________________________________________________________Other Adult involved with patient: ____________________________________________ SS#__________________Relationship to child: Adoptive Parent Step Parent Legal Guardian Foster Parent Or:_______________1. Address_______________________________ City_________________ State_________ ZipCode ______________2. Phone: home#______________________ cell# __________________________ wk#_______________3. Employer______________________________ Occupation___________________________4. Level of Education: Dropped out H.S. Trade Bachelor Master’s PhD/MD Other:____________________5. Mental illness, parent or family? NO YES:_________________________________________________________________________________________________________________________________________________________6. Substance abuse, parent or family? NO YES: _______________________________________________________Other adult involved with patient: _________________________________________SS#______________________Relationship to child: Adoptive Parent Step Parent Legal Guardian Foster Parent Or:_______________1. Address_______________________________ City_________________ State_________ ZipCode _______________home#______________________ cell# __________________________2. Employer______________________________Occupation_____________________________wk#_______________3. Level of Education: Dropped out H.S. Trade Bachelor Master’s PhD/MD Other:____________________4. Mental illness, parent or family? NO YES:____________________________________________________________5. Substance abuse, parent or family? NO YES:_________________________________________________________4

Describe any sleep problems (onset, provocation, frequency): _____________________________________________________________________________________________________________________________________________Describe any appetite problems (onset, provocation, frequency): _____________________________________________________________________________________________________________________________________________Describe any pyromania (fire setting): ___________________________________________________________________________________________________________________________________________________________________Describe any theft: __________________________________________________________________________________________________________________________________________________________________________________Describe any cruelty to animals: _______________________________________________________________________________________________________________________________________________________________________Describe any verbal abuse/swearing: ___________________________________________________________________________________________________________________________________________________________________Describe any history of temper tantrums (recent?, if previous, when they stopped):_______________________________________________________________________________________________________________________________Describe any destruction of property/vandalism: __________________________________________________________________________________________________________________________________________________________Describe any enuresis, encopresis, or urinating in inappropriate places: ________________________________________________________________________________________________________________________________________Describe extent of any alcohol use or drug use or smoking:__________________________________________________________________________________________________________________________________________________Describe any lying: _________________________________________________________________________________________________________________________________________________________________________________Describe any running away: ___________________________________________________________________________________________________________________________________________________________________________Describe any poor hygiene: ___________________________________________________________________________________________________________________________________________________________________________Describe any impulsive behavior (doing without thinking): ___________________________________________________________________________________________________________________________________________________Describe any problems with memory or concentration (onset): _______________________________________________________________________________________________________________________________________________Describe any risky behavior? __________________________________________________________________________________________________________________________________________________________________________Describe any problems playing with others (is child invited to others’ houses for day, overnight): ____________________________________________________________________________________________________________________Describe any problems with peer group (what is typical relationship like with peers?): __________________________________________________________________________________________________________________________Describe any inappropriate sexual behavior (public masturbation, fondling, exposing self, etc.):______________________________________________________________________________________________________________________How has the family reacted to the patient’s problems? ____________________________________________________________________________________________________________________________________________________6

PAST TREATMENT HISTORYWhere has the patient received therapeutic services in the past? (Most recent first, I-Inpatient, O-Outpatient)Name of Agency/Therapist Dates Level Primary Referring Problem(s)1) ______________________________ __________ I O _______________________________________2) ______________________________ __________ I O _______________________________________3) ______________________________ __________ I O _______________________________________4) ______________________________ __________ I O _______________________________________5) ______________________________ __________ I O _______________________________________Other services received: (and reasons previous services were stopped)Case Management: __________________________________________________________________________________In Home Family Based Services/Dates: _________________________________________________________________Parenting Classes/Dates: ________________________________________________________________________Neurological Evaluations/Dates: ________________________________________________________________________Any Prior Psychological Testing? NO YESWhen: _________________________, Where:___________________________ By whom:_________________________Why:____________________________________________________________________________ I.Q.______________Previous DSM IV Diagnosis’ indicated:Is this diagnosis from: Shodair Other: _____________________________________ Date: _____________AXIS I: ______________________________________________________________________________AXIS II: ______________________________________________________________________________AXIS III: ______________________________________________________________________________AXIS IV: ______________________________________________________________________________AXIS V: GAF= ______________________CHILD'S DEVELOPMENTAL HISTORYChild’s Current Height __________________________ Child’s Current Weight __________________________________Problems during pregnancy/birth? NO YES:________________________________________________________________________________________________________________________________________________________________Any history of prenatal substance exposure?: NO YES:__________________________________________________Any history of postpartum depression? NO YES:________________________________________________________When did the child start walking? _________________ talking? __________________ toilet trained? _____________Any periods where child regressed? NO YES:_________________________________________________________________________________________________________________________________________________________Any negative responses to separation from parents, feeding schedules, change? NO YES ___________________________________________________________________________________________________________________Medical/Accidents? NONE PROB:_____________________________________________________________________7

Any behavior or temperament problems? NO YES:_______________________________________________________NEGLECT AND ABUSE HISTORYAny history of physical abuse? NO YES? ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Any history of sexual abuse (including rape)? NO YES? ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Any history of neglect? NO YES? _______________________________________________________________________________________________________________________________________________________________________Any exposure to violence (movies or domestic violence)? NO YES:_____________________________________________________________________________________________________________________________________________Has Social Services ever investigated the family or patient? NO YESWhen? Why? Findings/Result of Investigation1) ______________ ___________________________ ______________________________________________2) ______________ ___________________________ ______________________________________________EDUCATIONAL HISTORYCurrent School? _______________________________________________ Current Grade? ___________________Name of primary school contact: _______________________________________________________________________Special education services or 504 plan? NO YES: _________________________________________________________Learning disabilities? NO YES: ________________________________________________________________________Peer/Teacher Relations? _____________________________________________________________________________Preferred Learning Method: Visual Auditory TactileRecent school performance (grades, behavior):____________________________________________________________________________________________________________________________________________________________Number of days of school missed in past year? 0-5 6-10 11-15 >15ENVIRONMENTAL AND CULTURAL FACTORSCultural and Spiritual Needs/IssuesSpiritual affiliation? __________________________________________________________________________________Active in cultural or spiritual activities? NO YES: _______________________________________________________Cultural/environmental factors impeding accessibility to treatment? NO YES: __________________________________8

Leisure/Recreation InterestsWhat are the patient’s interests/hobbies?: ________________________________________________________________Hours of TV, video games, computer per week? 25Environmental NeedsPatient has stable housing? YES NO: _____________________________________________________________Neighborhood safe? YES NO: ____________________________________________________________________Discharge Placement after Residential Treatment: ______________________________________________________________________________________________________________________________________________________Available Community ResourcesWhat support systems or community resources does the family have access to? Church Recreation Center Mental Health Services D.P.H.H.S Probation Neighborhood Community Center Extended Family Advocacy Group Neighbors Other: ___________________ Other: ____________________ Other: _______________________________________________________________Signature of Person completing this form____________________Date9

ADDRESS WORKSHEETLegal GuardianName:Address:City, State, Zip:Home Phone Number:Cell Number:Work Phone Number:Fax Number:Relationship:Case ManagerName:Agency:Address:City, State, Zip:Work Phone Number:Cell Number:Direct Phone Number:Fax Number:TherapistName:Agency:Address:City, State, Zip:Work Phone Number:Cell Number:Probation OfficerName:Agency:Address:City, State, Zip:Work Phone Number:Cell Number:Medication ManagementName:Agency or Clinic:Address:City, State, Zip:Work Phone Number:Cell Number:Direct Phone Number:Fax Number:Direct Phone Number:Fax Number:Direct Phone Number:Fax Number:Other (ie: DFS worker, CASA worker, Guardian ad Litem, etc.)Name/Relationship:Agency:Address:City, State, Zip:Work Phone Number:Direct Phone Number:Cell Number:Fax Number:U:\Admit Social Hx.forms\RTC Info Sheet Summary Revised: 5/200610

Montana Medicaid and Mental Health Services PlanAcute Inpatient Hospitalization/Residential Treatment CareFor Individuals under 21CERTIFICATE OF NEED□Check One: Acute inpatient: (Medicaid Only) Residential Treatment Center: Recipient Name:Date of Birth:Address:SSN:Admitting Facility:Proposed Admission Date:Medicaid/MHSP ID Number:Provider Number:Expected Discharge Date:At the time of admission the interdisciplinary team certifies the following:1. Ambulatory care resources available in the community do not meet the treatment needs of the recipient;(include documentation)2. Proper treatment of the recipient’s psychiatric condition requires services on an inpatient basis under the directionof a physician; (include documentation)3. The services can reasonably be expected to improve the recipient’s condition or prevent further regression so thatthe services will no longer be needed. (include documentation)Print/Type Name of Physician Team MemberTitleSignature of Physician Team MemberDatePrint/Type Name of Mental Health ProfessionalTitleSignature of Mental Health ProfessionalDatePrint/Type Name of Case Manager (Required for RTC only)Mental Health CenterSignature of Case Manager Date Telephone Number11

AUTHORIZATION FOR RELEASE OF HEALTH CARE INFORMATIONSHODAIR HOSPITAL2755 COLONIAL DRIVEP.O. BOX 5539 HELENA, MT 59604(406) 444-7500 OR 1-800-447-6614NAME OF PATIENT: _______________________________________________________________________BIRTHDATE: _________________________I hereby authorize Shodair Hospital to:MEDICAL RECORD NUMBER: ________________________Request information from:Disclose information to:Name/Agency:________________________________________________________________Address:__________________________________________________________________________________City, State, Zip:____________________________________________________________________________Phone Number: ______________________________Fax Number: ________________________________This information will be used to facilitate evaluation, treatment, and aftercare services for the patient and the family.INFORMATION REQUESTED/TO BE DISCLOSED: (CHECK ALL THAT APPLY)H&P/Medical Educational Psychiatric/PsychologicalOffice Notes Consultations Chemical Abuse/DependenceLab/Special Reports Treatment Plans Discharge SummaryImmunization Record Social History LegalOther (Please specify): ________________________________________________________________________This authorization will remain valid for a period of 30 (thirty) months from date of signature unless revoked before that time asdescribed below.I understand that this authorization for release of information may be revoked at any time in writing unless disclosure is required toeffectuate payments for health care that has been provided or other substantial action has been taken in reliance on the authorization.Leaving treatment at Shodair against medical advice does not, in and of itself, constitute a revocation of this authorization for releaseof information. Shodair Hospital may not condition treatment or payment on whether an individual signs this authorization.The potential exists for information disclosed pursuant to this authorization to be re-disclosed by the recipient and no longer beprotected by federal law. The undersigned person(s) agree to indemnify and hold harmless Shodair Hospital and its employees fromall claims or liability that may arise as a result of Shodair’s compliance with this authorization._____________________________________Date_______________________________________________________Signature of Parent/Legal Guardian (Circle Applicable Status)_____________________________________Witness________________________________________________________Signature of PatientPROHIBITION ON REDISCLOSURE: This information has been disclosed to you from records whose confidentiality is protected byFederal Law. Federal Regulations (42 C.F.R.) Part 2 prohibit you from making any further disclosure of this information except with thespecific written consent of the person to whom it pertains. A general authorization for the release of medical or other information ifheld by another party is not sufficient for this purpose. Federal Regulations state that any person who violates any provision of this lawshall be fined not more than $500 in the case of the first offense and not more than $5,000 in the case of each subsequent offense.* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *For Shodair Use Only: Date Records Requested ____________________ Date Records Received ____________________ROI.1/W.FILE/RELEASES FD: 6/22/00 REV: 4/03 REV: 5/0612