Psych
hiatric Residen
R
ntial Trreatmen
nt Facillity
Com
mpleted by::
Date:
me:
Resident’s Nam
Resident’s Datte of Birth:
patient/Currrent Provider:
Outp
(Include contac
ct information)
Refe
erral Sourc
ce:
(Include contac
ct information)
Re
equired Doc
cumen
nts: (to be compleeted by NBBHS-PRTF sstaff)
P
Please prov
vide curren
nt versions
s of the following
REQUES
STED
OBTAINE
ED
DEM
MOGRAPHIC PRO
OFILE (AT
TTACHED
D)
CUS
STODY DOCUMEN
NTATION
PYS
SCHIATRIIC/PSYCO
OLOGICA
AL EVAL
CLIN
NICAL RE
ECORDS
EDU
UCATION
NAL RECORDS/IEP
COU
URT ORD
DERS
Cop
pies of Birth Certifficate/SS Card/Ins
surance
Card
d/Immunization Card
NBHS
S-PRTF Applicattion Rev. 8/2013
1
NBHS-PRTF
Voluntary Placement by Family
Voluntary Placement by State Agency
Resident Label:
Resident Demographics
Resident’s First
Name
MI
Last Name
Address
DOB
Age
Sex
City
Religious
Preference
Race
SSN
State
Zip
County
Place of Birth
Primary
Insurance Company
Phone #
Subscriber
Group Number
Policy Number
Employer
Secondary
Insurance Company
Phone #
Subscriber
Group Number
Policy Number
Employer
DOB
DOB
SSN
SSN
Primary Referral Source
Primary Referral Agency
Primary Referral Phone #
Secondary Referral Source
Secondary Referral Agency
Secondary Referral Phone #
Primary Care Physician
Name of Practice
City/State
Phone
NBHS-PRTF Application Rev. 8/2013
2
NBHS-PRTF
Resident Label:
Parent / Legal Guardian Information
Parent/Guardian #1
DOB
SSN
Address
Phone(s)
Employer
Address
Parent/Guardian #2
DOB
SSN
Address
Phone(s)
Employer
Address
Biological Mother’s Name
Emergency Contact Name
Relationship
Work Phone
Relationship
Work Phone
Biological Father’s Name
Relationship to
Resident
Emergency Contact
Phone
City, State
Persons Living in the Home
Name
Age
Relationship to Resident
NBHS-PRTF Application Rev. 8/2013
3
NBHS-PRTF
Resident Label:
DHH/DCFS Custody
Date Placed
Reason for Placement
History of Emotional / Physical / Sexual Abuse or Neglect
Type of Abuse
Yes
If Yes, explain :
Abuser/ Relationship to
Resident
No
Date/
Age Abused
Reported
(Yes or No)
Founded or
Unfounded
Is resident a sexual perpetrator?
*Any/all abuse (disclosed during assessment) must be reported by the assessor within 24 hours to the DCFS
Call 1-855-4LA-KIDS (1-855-452-5437) toll free 24 hours a day, 365 days a year and documented below:
Staff Initials
Date Reported
Time
Reported to appropriate staff?
LEGAL HISTORY
Juvenile Court Involvement?
Current Charges Pending?
If Yes, Details:
FINS Filed?
If Yes, Date Filed:
Is Resident Currently on
Probation?
If Yes:
Is Resident Court Ordered to TX?
Does Resident have upcoming
court date?
Probation Officer
Phone #
Parish
If Yes, Order Date:
If Yes, Court Date:
Where:
Has Resident ever been
arrested?
If Yes, List charges:
Has Resident ever been placed in
detention?
If Yes:
Date
Where
Reason
NBHS-PRTF Application Rev. 8/2013
4
NBHS-PRTF
Resident Label:
Educational Background
Schools Resident Has Attended
Grade(s)
Year(s)
Contact Person/ Title
Current
Previous
Other
Yes
No
# of times
in last year
Type of Issue
Reason/Explain
Truancy/Skips
Suspensions
Expulsions
Quit School
Additional Educational Comments:
NBHS-PRTF Application Rev. 8/2013
5
NBHS-PRTF
Resident Label:
Chief Complaint/Precipitating Event: (Narrative)
NBHS-PRTF Application Rev. 8/2013
6
NBHS-PRTF
Resident Label:
HISTORY OF SUICIDAL/HOMICIDAL IDEATIONS/GESTURES/ATTEMPS
Dates or Age
SI/HI
SG/HG
SA/HA
HISTORY OF ANY SPECIAL TREATMENT
PROCEDURES WHILE IN OTHER
PLACEMENTS?
Date
Specific Plan/Method
YES
Outcome/Result
NO
Place
Method
Outcome
If Yes, Details: ____________________________________________________________
TREATMENT HISTORY
TYPE
DATES
From
To
FACILITY
MD/THERAPIST
Reason for Treatment
CURRENT MEDICATION
Compliant
Medication
Dosage
Frequency
If not Compliant, Explain
YES
NO
NBHS-PRTF Application Rev. 8/2013
7
NBHS-PRTF
Resident Label:
Medical Problems/ Illness
Current
Past
Allergies (Food/Drug)
Developmental Delays
Approximate Height
Additional Medical Comments to include current tx and medications for
medical history (be specific):
Approximate Weight
High Risk for Falls?
Sexually active: Yes
No
If yes, date of last known sexual contact _______________
Gender identification: _________________________________________________________
Birth Control Method:__________________________________________________________
Reviewing Staff Signature: _______________________________ Date: _______ Time: ________
Clinical Staff Signature: _________________________________ Date: _______ Time: ________
Medical Staff Signature: _________________________________Date: _______ Time: ________
Program Dir. Signature
_________________________________Date: _______ Time: ________
Approved: _________________________________
Date: _______ Time: ________
Denied:
Date: _______ Time: ________
_________________________________
NBHS-PRTF Application Rev. 8/2013
8