Tanager Place

Child's Name: DOB:
SS#: Medicaid #:  Female Male

Has the child been adjudicated a CINA or Delinquent?  Yes No

Behavioral Concerns:
 Hyperactive Inattentive Oppositional Depressed mood Self-abusive behaviors Easily frustrated Anger outbursts Decreased energy and motivation Wetting pants Soiling pants Bedwetting Psychosis Fire setting Stealing Lying Bullying Risk taker Impulsive Peer and social issues School difficulties Poor hygiene Sexual acting out Property destruction

Substance abuse:  Alcohol Marijuana Cocaine Cigarettes Other:
 Runaway history Overnight Frequency, length & dates:
 Suicidal thoughts / threats Attempts Dates:
Physical aggression toward:  People Animals Weapons
 Victim of physical abuse Sexual abuse Emotional abuse
By whom/when:
Traumatic events:

Psychiatric / Medical Information

Psychiatric Diagnosis (if applicable):

Medications and Dosages (if applicable):

Current or Past Illnesses/Conditions (check all that apply and provide detail below):
 MRSA RSV Diabetes Heart disease / heart murmur Chicken pox Measles Mono Scarlet fever Seizure disorder Foot and mouth disease Ehlers-Danlos Shingles Marfans Pregnancy Injectable medications Catheters Feeding tube

Special dietary needs:
Physical or communication limitations:
Child or family requires an interpreter. If yes, what language?
Further details:

Height: Weight: Allergies:

Primary Care Clinic: Physician:
Address/City/State: Phone:

Psychiatrist (medication management):
Address/City/State: Phone:

Psychologist:
Address/City/State: Phone:

Therapist/Counselor:
Address/City/State: Phone:

DHS worker/JCO: County:
Address/City/State:
Phone Email:

Attorney/Guardian Ad Litem:
Address/City/State:
Phone Email:

Other Service Providers:
One per line including the Name, Address/City/State, and Phone.

Out of Home Placements (hospitalizations, surgeries, foster care, shelter, residential treatment):
One per line including the Description and Start & End Dates.

Previous Services (psychiatrist, physician, therapist, DHS, mental health waiver, in-home services, etc):
One per line including the Description and Start & End Dates.

School Currently Attending:
Address/City/State:
Grade: Special Education Services: Current IEP:  Yes No
Length of time at this school:

Functioning Level: IQ: (if available) OR
Rate child’s intellectual capacity:  below average average above average

Who does child live with?

Where is child living currently? Length of time there: /

Caregiver #1: Name:
Relationship Length of time in child’s life:
 Biological Adopted Step Legal Guardian Other

Address:
City / State:
Home Phone: Cell: Work:
Email: Occupation:

Caregiver #2: Name:
Relationship Length of time in child’s life:
 Biological Adopted Step Legal Guardian Other

Address:
City / State:
Home Phone: Cell: Work:
Email: Occupation:

Caregiver #3: Name:
Relationship Length of time in child’s life:
 Biological Adopted Step Legal Guardian Other

Address:
City / State:
Home Phone: Cell: Work:
Email: Occupation:

Siblings/Others in the home:
One per line including the Name, Sex, Age, and Relationship (Full/Half/Step/Other).

Recent major family changes (losses, separations, divorce, illnesses, deaths, moves, etc):

Why are you seeking treatment now?

What expectations do caregivers have for treatment?

What expectations does the child have for treatment?

Where will the child go after treatment?

Who is recommending placement?

Is the child covered by private insurance?  Yes No
Insured's Name:
Date of Birth: SS #:
Address/City/State:
Relationship to child

Insurance Company Name:
Address/City/State:
Phone #: Policy Number:

Employer Name:
Address/City/State:
Does this insurance cover any/all of the following? (Please check all that apply)
 Hospital/Physician Dental Prescription Vision Mental Health

(If yes, recognize that you may be required to pay some or all of these amounts towards the cost of the child’s care)

Individual completing application:
Relationship to child:
Best way to contact you? Phone: Email:

How did you find out about our services?