693 Leesville Road
Lynchburg, VA 24502
434.200.5700
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 434.200.5700, by voice mail at
434.200.5025, 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 have been
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
434.200.5700
APPLICATION FOR ADMISSION
Bridges Treatment Center
*Name of Applicant ___________________________________________________________
DOB _______________ Age _________
Gender M / F
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
434.200.5700
SOCIAL HISTORY QUESTIONNAIRE
Bridges Treatment Center
IDENTIFYING INFORMATION
Date of application: __________________________________________________________
Person completing questionnaire: _______________________________________________
Relationship to applicant: ______________________________________________________
Applicant Name: _______________________________ DOB: _____________ Age: ______
Gender: M / F
Address: _________________________________________________
SS#: _____________________________________ Phone: __________________________
School most recently attended: ___________________________ Current Grade: _________
Religion (if applicable): _______________________________________________________
Name of legal guardian: _______________________________________________________
With whom does the applicant live? ______________________________________________
REASON FOR REFERRAL
Who referred the applicant to Bridges? ____________________________________________
Please list the reason(s) the applicant was referred for treatment: ________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
SUMMARY OF RELEVANT HISTORY
When did the problem begin?____________________________________________________
What were the precipitating factors? ______________________________________________
____________________________________________________________________________
Describe the applicant’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 applicant 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 applicant as an infant:
Very active
Restless
Normally active
Sluggish
Fragile
Sickly
Happy
Cute
Colicky
Irritating
Healthy
Responsive
Irritable
Easily satisfied
Did not like
being held
Quiet
Crying
Good
Demanding
Who was the major caretaker before applicant began school? (Include parents, daycares,
babysitters or relatives): ____________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Please give names and relationships of any other people who were important in rearing
the applicant (grandparents, step-parents, foster parents, etc.): _____________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
5
At what age did puberty begin? __________ How did the applicant react? ___________
________________________________________________________________________
________________________________________________________________________
Please check any of the following that are a problem or have been a problem for the
applicant:
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 applicant have any current medical or physical problems? _________________
________________________________________________________________________
________________________________________________________________________
Please list medications and/or treatment for the above problems: ____________________
_______________________________________________________________________
Please list any allergies the applicant has: ______________________________________
________________________________________________________________________
Please list any major illnesses, hospitalizations, convulsions, seizures, high fevers or
medications that the applicant has had, with age(s): ______________________________
________________________________________________________________________
________________________________________________________________________
Are there any dietary or weight issues or treatment for these?_______________________
________________________________________________________________________
Does the applicant 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 applicant’s adjustment to pre-school, nursery school or kindergarten: _____
________________________________________________________________________
________________________________________________________________________
Has the applicant had any attendance or behavioral problems in school? _____ If yes,
please describe (give age and grade): _________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Has the applicant ever repeated a grade? _____ If yes, which grade(s)?
________________________________________________________________________
Is the applicant in special education classes? ______ If yes, what is the current
educational level? ______ Date of last IEP? ____________________________________
7
List schools the applicant 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 with dosage and frequency): ________________________________
________________________________________________________________________
________________________________________________________________________
Has the applicant 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 applicant (hobbies, talents, sports)? ___________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Describe the applicant’s friendships and social network: __________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
What interests and activities do the applicant and family share together? _____________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Has the applicant 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 applicant’s best qualities? ___________________________
________________________________________________________________________
________________________________________________________________________
FAMILY INFORMATION
Type of residence: ________________________________________________________
Where does the applicant sleep? _____________________________________________
Does the applicant share a room? ____________________________________________
Who currently lives in the household? ________________________________________
_______________________________________________________________________
_______________________________________________________________________
9
Please indicate any changes of locality the family has experienced:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Does the applicant 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:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
APPLICANT’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 applicant’s relationships with his/her parents: ___________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Describe applicant’s relationships with siblings (include names): ___________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Describe applicant’s relationships with relatives and significant others: ______________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
12
Please list names and relationships of any other people living in the same household as
the applicant: ____________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Describe any separations from the parents the applicant 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 APPLICANT
List any stressors on the family (medical, financial, emotional, etc): _______________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Has the applicant 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 applicant 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
434.200.5700
Admission Day Information
In order to provide a smooth transition for the resident, 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 the resident, please keep in mind that Bridges does not provide storage
space. The following list will be of use when gathering the resident’s belongings:






A weekend bag/suitcase to remain on campus for the resident 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 applicants. You
may leave money for the resident 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 applicants, staff and visitors. We encourage healthy lifestyles
and expect you to further this for your resident by not using tobacco products during your visit
and not providing tobacco products to the resident 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 the resident 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, 7/14
16
CSA Reimbursement Rate Certification
Residential Treatment and Treatment Foster Care
Name of Resident: ________________________________________________________
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 resident 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*
*Medicaid does not cover
Rates Effective: July 1, 2014 – June 30, 2015
18
DAY
$247.71
$101.18
$348.89
$120.00
$468.89
$37.00
$118.00
$47.00
$95.00
$78.00
$118.00
$47.00
$126.00
$75/hour,
plus
$.56/mile
YEAR
$90,414.15
$36,930.70
$127,344.85
$30,240.00
$157,584.85
$13,542.00
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