Inpatient Referral

Client Name*

First Last

Client Date of Birth*

Client Gender*

Male
Female

Referrer Name*

First Last

Referrer Email Address*

Referrer Phone Number*

Referrer Relationship to Client*

About This Form

Tanager Place is providing this form to potential inpatient clients to aid in and bring better understanding to our qualifications process.

In some instances, we are unable to provide inpatient services to a child. This could be due to special health or other considerations. Answers to some questions on this form may automatically disqualify a child from services. In those instances, information is provided on additional resources. Answers to other questions are potentially disqualifying, but more information is needed to make a full determination.

Disqualifying circumstances:

Inability to attend public school
Undergoing cancer or radiation treatment
Confinement to a wheel chair
Pregnancy
Diabetes
Impaired hearing

Your child deserves the best possible care. Please provide as much information as possible.

Can the client attend public school?*

Yes
No

At this time, Tanager Place can only accept youth who can attend public school as part of our Inpatient Program.

You may want to browse available outpatient services.

Does the client have diabetes?*

Yes
No

At this time Tanager Place cannot accept clients with diabetes into our Inpatient Program.

You may want to browse available outpatient or school based services.

Is the client currently pregnant?*

Yes
No

At this time Tanager Place cannot accept clients who are pregnant into the Inpatient Program.

You may want to browse available outpatient or school based services.

Is the client currently a cancer patient or undergoing radiation treatment?*

Yes
No

At this time Tanager Place cannot accept clients undergoing cancer treatment into the Inpatient Program.

You may want to browse available outpatient or school based services.

Is the client wheelchair bound?*

Yes
No

At this time the Tanager Place Inpatient Program does not accept clients confined to a wheelchair.

You may want to browse available outpatient or school based services.

Is the client hard of hearing?*

Yes
No

At this time clients who are hard of hearing are not eligible for the Tanager Place Inpatient Program.

You may want to browse available outpatient or school based services.

Is this a court-ordered or similar committal?*

Yes
No

Child In Need of Assistance (CINA)?*

Yes
No

JCO/Delinquent?*

Yes
No

Does the client have a history of fire setting?*

Yes
No

Please provide additional details about the client's history of fire setting in the space below:

Does the client have a history of sexualized behavior?*

Yes
No

Please provide additional details about the client's history of sexualized behavior in the space below:

Does the client have a criminal history or criminal charges stemming from sexual offenses?*

Yes
No

Please provide additional details about the client's history of criminal sexual offenses in the space below:

Does the client have any criminal history or criminal charges?*

Yes
No

Please provide additional details about the client's criminal history or charges in the space below:

Does the client experience seizures or epilepsy?*

Yes
No

Please provide additional details about the client's experience with seizures/epilepsy in the space below:

Does the client have congenital heart problems?*

Yes
No

Please provide additional details about the client's congenital heart problems in the space below:

Prior Service & Treatment History

Psychiatric Hospitalization*

Yes
No

Where?

When? (Month/Year)

Shelter Stays*

Yes
No

Where?

When? (Month/Year)

Residential Treatment*

Yes
No

Where?

When? (Month/Year)

Does the client see a psychiatrist?*

Yes, currently
Yes, previously
No

Please provide current provider name and length of treatment

What was the length of the previous treatment?

Does the client see a psychologist?*

Yes, currently
Yes, previously
No

Please provide current provider name and length of treatment

What was the length of the previous treatment?

Does the client see a therapist?*

Yes, currently
Yes, previously
No

Please provide current provider name and length of treatment

What was the length of previous treatment?

Does the client receive BHIS or other skill-building services?*

Yes, currently
Yes, previously
No

Please provide current provider name and length of treatment

What was the length of previous treatment?

Does the client receive PIH services?*

Yes, currently
Yes, previously
No

Please provide current provider name and length of treatment

What was the length of previous treatment?

Does the client have a Children's Mental Health Waiver?*

Yes, currently
Yes, previously
No

Please provide current provider name and length of treatment

What was the length of previous treatment?

Is the client receiving other related services not yet reported?*

Yes, currently
Yes, previously
No

Please provide additional details including treatment type, provider and length of service

Does the client have an intellectual disability?*

Yes
No

Please provide additional details about the client's disability in the space below:

Does the client have an autism diagnosis?*

Yes
No

Full scale IQ, if known

Documentation Upload

If applicable and available, please upload documentation and/or records related to treatment services.

Symptomology: Harm to self or others

Non Suicidal Self Injury (NSSI)*

Past History
Current History
None

Suicidal*

Past History
Current History
None

Homicidal*

Past History
Current History
None

If there is a past or current history for any of the above, please use the space below to provide additional details.

Symptomology: Aggression

Physical Aggression*

Past History
Current History
None

Verbal Aggression*

Past History
Current History
None

Destruction of Property*

Past History
Current History
None

Quick to Anger*

Past History
Current History
None

Cruelty to Animals*

Past History
Current History
None

If there is a past or current history for any of the above, please use the space below to provide additional details.

Symptomology: Social

Fights with Others*

Past History
Current History
None

Argues*

Past History
Current History
None

Difficulty with Peers*

Past History
Current History
None

If there is a past or current history for any of the above, please use the space below to provide additional details.

Symptomology: Trauma

Death of a Family Member*

Past History
Current History
None

Victim of Crime/Violence*

Past History
Current History
None

Bystander to Crime/Violence*

Past History
Current History
None

Domestic Violence*

Past History
Current History
None

Sexual Abuse*

Past History
Current History
None

Physical Abuse*

Past History
Current History
None

Emotional/Mental Abuse*

Past History
Current History
None

If there is a past or current history for any of the above, please use the space below to provide additional details.

Symptomology: Substance Abuse

Alcohol Use*

Past History
Current History
None

Illicit Substance Use*

Past History
Current History
None

Prescription Abuse*

Past History
Current History
None

Nicotine Use*

Past History
Current History
None

If there is a past or current history for any of the above, please use the space below to provide additional details.

Symptomology: Avoidance

Runs Away*

Past History
Current History
None

If there is a past or current history for any of the above, please use the space below to provide additional details.

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