693 Leesville Road Lynchburg, VA 24502 434-947-5700 APPLICATION FOR ONLINE SITE Thank you for your interest in our program at Bridges Treatment Center. We hope the following information will be helpful in making application for placement. At any time during the process, please contact Dee Edwards at Bridges Treatment Center at 434-947-5700, by voice mail at 434947-5851, ext. 1, or by e-mail at dee.edwards@centrahealth.com if there are questions about the process or the appropriateness of the applicant for our program. Once applications are completed, you can submit them to: Dee Edwards Bridges Treatment Center 693 Leesville Road Lynchburg, VA 24502 FAX: 434-947-5708 Attachments: 1. Application (pages 2-3) -- Please include appropriate attachments. 2. Social History Questionnaire -- This must be completed by the day of admission by the legal guardian (pages 4-14). 3. Admission day information (pages 15-16). 4. CSA Reimbursement Rate Certification and current rates for services (pages 17-18). 693 Leesville Road Lynchburg, VA 24502 434-947-5700 APPLICATION FOR ADMISSION Bridges Treatment Center *Name of Applicant ___________________________________________________________ DOB _______________ Age ________________ SS# ________________________________ Current Placement _____________________________________________________________ *Legal Guardian ______________________________________________________________ Relationship of Applicant ________________________________________________________ Address ______________________________________________________________________ Phone Number ________________________________________________________________ *Referring Agency ____________________________________________________________ Contact Person _______________________________ Phone # __________________________ Address ______________________________________________________________________ Please complete and attach all information: Required Information Supporting Information Current Medications: _________________________ Physical Needs ___________________________________________ **Please attach immunization record** ___________________________________________ Allergies: __________________________________ **If applying to the group home please attach birth certificate and Social Security Glasses: Yes Card** / No Dental /Orthodontic History: ___________________ ___________________________________________ Handicapping Conditions/Medical Needs: ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ ___________________________________________ 2 School System/LEA: _________________________ ___________________________________________ **Please attach current IEP or report Current Grade Placement: _____________________ card/transcript if not special education** Special Education Status and Eligibility Status: ___________________________________________ ___________________________________________ Related Services: ____________________________ Educational Needs Mental Health, Emotional Psychological Needs and Current Psychiatric Diagnosis: Significant family dynamics: **Please attach Social History Questionnaire, most recent Psychological Testing and past Has a family member or relative ever been or is treatment histories** currently being treated at Bridges? Behavioral Management Needs Protection Needs (self-injurious, running away, or sexually acting out behaviors): __________________ ___________________________________________ ___________________________________________ Developmental Needs: ________________________ Funding Information FAPT/CPMT Approval: YES NO PENDING _________________________________ **Please attach current CANS, Certificate of Need and Rate Medicaid Eligible: YES NO Certification Sheet** PENDING _________________________________ **Medicaid Card and private insurance Private Insurance: YES NO card must be provided on admission** Policy Holder’s Name: ________________________ D.O.B.: ____________________________________ Suitability of Admission Date of Interview: ___________________________ Date of Interview: ________________ Date of Admission: __________________________ Interview Team Admit Milieu: _______________________________ Y / N Education: _____________________________ Y / N Therapist: _____________________________ Y / N Nurse: ________________________________ Y / N Comments: ________________________________ __________________________________________ __________________________________________ Date of Admission: _______________ Please return with attachments to Dee Edwards, Admissions Coordinator. 3 693 Leesville Road Lynchburg, VA 24502 434-947-5700 SOCIAL HISTORY QUESTIONNAIRE Bridges Treatment Center IDENTIFYING INFORMATION Date of application: __________________________________________________________ Person completing questionnaire: _______________________________________________ Relationship to resident: ______________________________________________________ Resident Name: _______________________________ DOB: _____________ Age: ______ Address: ___________________________________________________________________ SS#: _____________________________________ Phone: __________________________ School most recently attended: ___________________________ Current Grade: _________ Religion (if applicable): _______________________________________________________ Name of legal guardian: _______________________________________________________ Who does the resident live with? _______________________________________________ REASON FOR REFERRAL Who referred the resident to Bridges? ____________________________________________ Please list the reason(s) the resident was referred for treatment: ________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ SUMMARY OF RELEVANT HISTORY When did the problem begin?____________________________________________________ What were the precipitating factors? ______________________________________________ ____________________________________________________________________________ Describe the patient’s behavior before the problem began: _____________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 4 DEVELOPMENTAL HISTORY Was this pregnancy planned? ____ Full Term? _______ If no, how many months? _____ Birth weight? ____lbs ____ozs. Were medications/drugs/ alcohol used during pregnancy? ______ If yes, specify: __________________________________________ Were there complications during pregnancy and/or delivery? _____ If yes, please explain: _________________________________________________________________ Delivery: vaginal _____ Caesarian _____ At what age did the resident do the following? Sat unsupported Began to talk Began to walk Fed self with spoon Began toilet training Slept through the night Recognized strangers Spoke in short sentences Walked alone Put on clothes Completed toilet training Please comment on any difficulties with the following: Feeding: ________________________________________________________________ Sleeping: _______________________________________________________________ Talking: ________________________________________________________________ Walking: ________________________________________________________________ Toilet training: ___________________________________________________________ Check all which describe the resident as an infant: Very active Restless Sluggish Fragile Happy Cute Irritating Healthy Irritable Easily satisfied Normally active Sickly Colicky Responsive Did not like being held Quiet Crying Good Demanding Who was the major caretaker before resident began school? (Include parents, daycare, babysitter or relatives): ____________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please give names and relationships of any other people who were important in rearing the resident (grandparents, step-parents, foster parents, etc.): ______________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 5 At what age did puberty begin? __________ How did the resident react? ____________ ________________________________________________________________________ ________________________________________________________________________ Please check any of the following that are a problem or have been a problem for the resident: CURRENT PROBLEM PAST PROBLEM/AGE Thumb sucking Fire setting Destructiveness Nail biting Soiling pants Dressing problems Rocking Stuttering Sexual difficulties Nightmares Hyperactivity Under activity Clumsiness Too clean Bedwetting Suicidal thoughts Head banging Temper tantrums Breath holding Fears Lying Nervous twitches Stubbornness Indecisiveness Sloppiness Running away Drinking Drug use Stealing Cruelty to animals Excessive sexual behavior 6 MEDICAL HISTORY Does the resident have any current medical or physical problems? __________________ ________________________________________________________________________ ________________________________________________________________________ Please list medications and/or treatment for the above problems: ____________________ _______________________________________________________________________ Please list any allergies the resident has: _______________________________________ ________________________________________________________________________ Please list any major illnesses, hospitalizations, convulsions, seizures, high fevers or medications that the resident has had, with age(s): _______________________________ ________________________________________________________________________ ________________________________________________________________________ Are there any dietary or weight issues or treatment for these?_______________________ ________________________________________________________________________ Does the resident have hearing problems or receive treatment for hearing problems? ____ ________________________________________________________________________ ________________________________________________________________________ Does the child wear glasses? _________ When was the last eye exam?_______________ When was the last dental exam? _____________________________________________ Are there any dental problems? ______________________________________________ EDUCATIONAL HISTORY Describe the resident’s adjustment to pre-school, nursery school or kindergarten: ______ ________________________________________________________________________ ________________________________________________________________________ Has the resident had any attendance or behavioral problems in school? _____ If yes, please describe (give age and grade): _________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Has the resident ever repeated a grade? _____ If yes, which grade(s)? _______________ Is the resident in special education classes? ______ If yes, what is the current educational level? ______ Date of last IEP? ______________________________________________ 7 List schools the resident has attended and grades completed at each school (include preschool and/or nursery school). SCHOOL AGE/GRADE GRADE AVERAGE Favorite subjects: _________________________________________________________ Least favorite subjects: ____________________________________________________ Academic strength(s): _____________________________________________________ Academic weakness(es): ___________________________________________________ MENTAL HEALTH TREATMENT HISTORY TYPE OF TREATMENT DATES (Start and Stop) REASON ACUTE HOSPITALIZATIONS 1. 2. 3. 4. OUTPATIENT TREATMENT 1. 2. 3. 4. HOME-BASED 1. 2. 3. Current medication(s) (dosage, frequency): ____________________________________ ________________________________________________________________________ ________________________________________________________________________ Has the resident completed psychological testing? ____ If yes, give date(s) and name(s) of evaluator(s). Please include copy of most recent testing. ______________________ ________________________________________________________________________ ________________________________________________________________________ 8 STRENGTHS/WEAKNESSES How is free time spent by the resident (hobbies, talents, sports)? ____________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Describe the resident’s friendships and social network: ___________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What interests and activities do the resident and family share together? ______________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Has the resident been employed or participated in volunteer work? __________________ Describe: _______________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What would you identify as the support system for this family? ____________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Do you or your child have any spiritual or religious beliefs that may impact his/her course of treatment while at Bridges? Yes ____ No _____ If yes, please describe: ________________________________________________________________________ ________________________________________________________________________ What do you believe are the resident’s best qualities? ____________________________ ________________________________________________________________________ ________________________________________________________________________ FAMILY INFORMATION Type of residence: ________________________________________________________ Where does the resident sleep? ______________________________________________ Does the resident share a room? _____________________________________________ Who currently lives in the household? ________________________________________ _______________________________________________________________________ _______________________________________________________________________ 9 Please indicate any changes of locality the family has experienced: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Does the resident currently have any pets? _____ If yes, please specify: _____________ Mother’s name: ______________________________ Age: ______ DOB: ____________ Address: ________________________________________________________________ Home phone: ____________________________ Social Security #: _________________ Educational Level: ______________________________ Religion: _________________ Occupation: _________________________________ Work phone: _________________ Employer: _______________________________________________________________ Military service and dates: __________________________________________________ If remarried, name of current spouse: _________________________________________ If deceased, date and cause of death: __________________________________________ Place of birth and where raised: ______________________________________________ ________________________________________________________________________ PREVIOUS MARRIAGES DATE OF DATE OF MARRIAGE DISSOLUTION MOTHER’S PARENTS NAME REASON AGE HEALTH OCCUPATION MARITAL STATUS MOTHER FATHER MOTHER’S SIBLINGS NAME 1. 2. 3. 4. 5. AGE Briefly describe relationships between mother, father and siblings in mother’s family: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 10 Father’s name: _______________________________ Age: _____ DOB: ____________ Address: ________________________________________________________________ Home phone: ____________________________ Social Security #: _________________ Educational level: _____________________________Religion: ____________________ Occupation: __________________________________ Work phone: ________________ Employer________________________________________________________________ Military Service and dates__________________________________________________ If remarried, name if current spouse___________________________________________ If deceased, date and cause of death___________________________________________ Place of birth and where raised ______________________________________________ Previous Marriages: DATE OF MARRIAGE DATE OF DISSOLUTION FATHER’S PARENTS NAME REASON AGE HEALTH OCCUPATION MARITAL STATUS MOTHER FATHER FATHER’S SIBLINGS NAME 1. 2. 3. 4. 5. AGE Briefly describe relationships between mother, father and siblings in father’s family: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ RESIDENT’S SIBLINGS (brothers and sisters, half- and step-siblings, living and deceased) NAME AGE RELATIONSHIP RESIDENCE EDUCATION OCCUPATION 11 Stepmother (if applicable): Name: _________________________________________________ Age: ____________ Address: ________________________________________________________________ Phone #: ____________________________ Occupation: _________________________ PREVIOUS MARRIAGES DATE OF DATE OF MARRIAGE DISSOLUTION REASON Stepfather (if applicable): Name: __________________________________________________________________ Address: ________________________________________________________________ Phone #: ____________________________ Occupation: _________________________ PREVIOUS MARRIAGES DATE OF DATE OF MARRIAGE DISSOLUTION REASON Describe resident’s relationships with his/her parents: ____________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Describe resident’s relationships with siblings (include names): ____________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Describe resident’s relationships with relatives and significant others: _______________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 12 Please list names and relationships of any other people living in the same household as the resident: _____________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Describe any separations from the parents the resident has experienced: ______________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Mental Health and/or drug and alcohol problems in the family (if for relatives, please specify if they maternal or paternal) NAME RELATIONSHIP DESCRIBE PROBLEM TO RESIDENT List any stressors on the family (medical, financial, emotional, etc): _______________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Has the resident lost any family members, friends or pets through death or separation? ______ If yes, please describe: ______________________________________________ ________________________________________________________________________ PHYSICAL AND/OR SEXUAL ABUSE PHYSICAL ABUSE SEXUAL ABUSE By Whom? At What Age? By Whom? At What Age? Has the resident had any legal or police involvement? __________ If yes, please explain: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 13 SUMMARY What are your goals for treatment? 1. ______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 2. ______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 3. ______________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Please include any other comments or special concerns you wish to make or additional information that you feel would be relevant to helping us understand the family. ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 14 693 Leesville Road Lynchburg, VA 24502 434-947-5700 Admission Day Information In order to provide a smooth transition for your child, the following information MUST be available on the day of admission. Completed social history form (found in the pre-admission packet). Name, address, phone number and social security number of birth parents and date of birth, when appropriate. Name, address and phone number of former physician and dentist. Medicaid card or other insurance card. List of current medications (please bring prescription labels). Additional medications will be supplies by Bridges. Please do not bring any medications. Medical information regarding current treatments; i.e., allergies, diabetes, dietary needs, eye glasses, etc. School address and contact person (please include phone numbers). IEP and/or current report card. * Immunization record must be included or the admission will be delayed. When packing for your child, please keep in mind that Bridges does not provide storage space. The following list will be of use when gathering your child’s belongings: A weekend bag/suitcase to remain on campus for the child when passes home are granted; large containers and suitcases will not be stored and will need to be taken back home. 7 days of seasonal clothing; casual clothing may include jeans and tee-shirts. Sturdy tennis shoes (non-marking soles). Bathing suit (all seasons). Gym clothing. Radio, clock, hairdryer, and other electrical appliances (which will need to be found in safe working conditions by Bridges maintenance department). 15 Tapes and posters may be brought. However, Bridges reserves the right to send articles back home with parents/guardians that are deemed countertherapeutic to our environment. Personal hygiene products. * Bridges does not provide clothing or spending allowances for the residents. You may leave money for your child with the milieu coordinator. This money will be monitored by staff. The following are provided by Bridges Treatment Center: Linens Laundry facilities and detergents Please keep in mind that Bridges Treatment Center provides a smoke-free environment, which includes our parking lots, for our residents, staff and visitors. We encourage healthy lifestyles and expect you to further this lifestyle for your child by not using tobacco products during your visit and not providing tobacco products to your child during passes or visits. Bridges Treatment Center serves children and adolescents from a variety of cultural, ethnic and religious backgrounds. In order to respect all national and religious holidays, and not to accidentally exclude anyone, Bridges Treatment Center will have seasonal festivals throughout the calendar year. These will incorporate the traditional holidays and customs and will, in some instances, incorporate the school schedule. While your child is in treatment, please be informed that the use of public transportation (planes, trains, buses, cars) by your child, without guardian/parent accompaniment, will not be allowed. If you have any further questions regarding these policies, please contact Gina Meadows, Director, RN, MSN, APRN, BC. * Please initial: __________ Revised 1/98, 4/06, 11/08, 06/10, 07/10, 06/11, 7/12, 7/13 16 CSA Reimbursement Rate Certification Residential Treatment and Treatment Foster Care Name of Child: ___________________________________________________________ Medicaid Number: ________________________________________________________ Residential Treatment or Foster Care – Case Management Provider: Bridges Treatment Center, 693 Leesville Road, Lynchburg, VA 24502 Provider Number: 1629172838 Community Policy and Management Team County/City: ____________________________________________________________ Address: ________________________________________________________________ Street ________________________________________________________________________ City State Zip Code I certify that the following rate, $_______________ per day, as been negotiated for the above child for Medicaid reimbursable (check one) . . . _____ Residential Treatment _____ Treatment Foster Care – Case Management The Medicaid rate noted should reflect the negotiated rate minus expected reimbursement from all other payment sources, such as Title IV-E. The total reimbursement from all other sources cannot exceed the Medicaid maximum rate for this service. This rate shall be effective for date of service beginning __________________________. **MONTH/DAY/YEAR** CPMT Signature: ________________________________________ Print Name: ____________________________________________ Title: _________________________________________________ Date: _________________________________________________ **Date must be of the current year** 17 RATES PER SERVICE UNIT Bridges Treatment Center SERVICE Room and Board – Title IV-E Combined Services SUBTOTAL Education* TOTAL Therapies – Individual, Group, Family Occupational Therapy Services – Evaluation Occupational Therapy Services – Cognitive Skill Development Speech Therapy Services – Individual Speech Therapy Services – Group Physical Therapy – Evaluation Physical Therapy – Therapeutic Activity Psychological* Travel Requested/Required by Placing Agency* DAY $247.71 $101.18 $348.89 $102.00 $450.89 $37.00 $118.00 $47.00 $95.00 $78.00 $118.00 $47.00 $126.00 $75/hour, plus $0.565/mile YEAR $90,414.15 $36,930.70 $127,344.85 $25,704.00 $153,048.85 $13,505.00 Per Session Per 15 minutes Per Session Per Session Per Session Per 15 minutes Per Hour N/A OFFERED 365 days 365 days 365 days 252 days 365 days Per Physician Order Per Physician Order Per Physician Order Per Physician Order Per Physician Order Per Physician Order Per Physician Order As Needed YEAR $29,200.00 $53,370.30 $82,570.30 N/A N/A OFFERED 365 days 365 days 365 days As Needed As Needed Brightwell Group Home (Effective 2/1/2010) SERVICE Room and Board* Therapeutic Services TOTAL Medical Management* Travel Requested/Required by Placing Agency* DAY $80.00 $146.22 $226.22 $25.00 $75/hour, plus $0.565/mile *Medicaid does not cover Rates Effective: July 1, 2013 – June 30, 2014 18