NORTHLAKE YOUTH ACADEMY
Psychiatric Residential Treatment Facility
23515 Hwy. 190 Mandeville, Louisiana 70470
Phone: 985-626-6534 Fax: 985-626-6398
Completed by:
Date:
Resident’s Name:
Resident’s Date of Birth:
Outpatient/Current Provider:
(Include contact information)
Referral Source:
(Include contact
information)
____________________________________________________________
____________________________________________________________
Chief Complaint/Precipitating Event: (Narrative)
NBHS-PRTF Application Rev. 9/2013
1
NBHS-PRTF
Voluntary Placement by Family
Voluntary Placement by State Agency
Resident Label:
Resident Demographics
Resident’s First
Name
MI
Weight
Last Name
DOB
Height
Eye
Color
Hair
Color
City
State
Address
Religious
Preference
Age
Sex
Race
SSN
Zip
County
Place of Birth
Primary Referral Source
Primary Referral Agency
Primary Referral Phone #
Secondary Referral Source
Secondary Referral Agency
Secondary Referral Phone #
Primary
Insurance Company
Phone #
Subscriber
Group Number
Policy Number
Employer
Secondary
Insurance Company
Phone #
Subscriber
Group Number
Policy Number
Employer
Primary Care Physician
Name of Practice
DOB
DOB
City/State
SSN
SSN
Phone
NBHS-PRTF Application Rev. 9/2013
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. 9/2013
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NBHS-PRTF
Resident Label:
DHH/DCFS Custody
Date Placed
Reason for Placement
History of Emotional / Physical / Sexual Abuse or Neglect
Type of Abuse
Abuser/ Relationship to
Client
Yes
If Yes, explain :
No
Date/
Age Abused
Reported
(Yes or No)
Founded or
Unfounded
Is client 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
YES
NO
Juvenile Court Involvement?
Current Charges Pending?
If Yes, Details:
FINS Filed?
If Yes, Date Filed:
Is Client Currently on Probation?
If Yes:
Probation Officer
Phone #
Is Client Court Ordered to TX?
Does Client have upcoming court
date?
Parish
If Yes, Order Date:
If Yes, Court Date:
Where:
Has Client ever been arrested?
If Yes, List charges:
Has Client ever been placed in
detention?
If Yes:
Date
Where
Reason
NBHS-PRTF Application Rev. 9/2013
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NBHS-PRTF
Resident Label:
Educational Background
Schools Client Has Attended
Grade(s)
Year(s)
Contact Person/ Title
Current
Previous
Yes
No
# of times
in last year
Type of Issue
Reason/Explain
Truancy/Skips
Suspensions
Expulsions
Quit School
Type of Test
Has Client been tested?
YES
NO
If Yes,
When
Results of Test
Psychological
ADHD/ADD
FSIQ
Score:
Learning Disability
Yes
No
Current Grade Level:
Is Client Currently in Resource/ Special Ed?
Above Average
Average
Below Average
Additional Educational Comments:
NBHS-PRTF Application Rev. 9/2013
5
NBHS-PRTF
Resident Label:
Behavioral/Social History
DEPRESSION
FREQUENCY
HISTORY
TYPE
N
D
W
M
N
30-60
days
3-12
months
Example of Last Episode
Depressed, Sad
Hopeless
Loss of Interest
Appetite Change
Insomnia
Decreased Energy
Sense of
Worthlessness
Somatic Complaints
Isolative
Mood Swings
Total ____ of 9
PSYCHOSIS
FREQUENCY
TYPE
N
D
W
HISTORY
M
N
30-60
days
3-12
months
Example of Last Episode
Delusions
Hallucinations
Disorganized
Speech
Disorganized
Behavior
Paranoia
Catatonic Behavior
Total ____ of 6
NBHS-PRTF Application Rev. 9/2013
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NBHS-PRTF
Resident Label:
MANIA
FREQUENCY
HISTORY
TYPE
N
D
W
M
N
30-60
days
3-12
months
Example of Last Episode/Notes
Elevated Mood
Grandiosity
Pressured Speech
Motor Agitation
Rapid Ideas
Decreased Need for
Sleep
Poor Judgment
Distractibility
Mood Changes
Hyper Sociality
Total _____ of 10
ANXIETY
FREQUENCY
TYPE
N
D
W
HISTORY
M
N
30-60
days
3-12
months
Example of Last Episode
Excessive Worry
Restlessness
Muscle Tension
Panic Attacks
Easily Fatigued
Total _____ of 5
NBHS-PRTF Application Rev. 9/2013
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NBHS-PRTF
Resident Label:
IMPULSIVITY
FREQUENCY
HISTORY
TYPE
N
D
W
M
N
30-60
days
3-12
months
Example of Last Episode/Notes
Distractibility
Failure to Complete
Work
“On-The-Go”
Fidgety
Poor Judgment
Poor School
Performance
Interrupts Others
Excessive Talk
Poor Concentration
Risk Taking
Total _____ of 10
OPPOSITIONAL DEFIANT
FREQUENCY
TYPE
N
D
W
HISTORY
M
N
30-60
days
3-12
months
Example of Last Episode
Loses Temper
Argues with Adults
Defies Rules
Blames Others
Annoys Others
Deliberately
Spiteful
Total _____ of 6
NBHS-PRTF Application Rev. 9/2013
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NBHS-PRTF
Resident Label:
CONDUCT ISSUES
FREQUENCY
HISTORY
TYPE
N
D
W
M
N
30-60
days
3-12
months
Example of Last Episode/Notes
Aggressive to
People
Aggressive to
animals
Destruction of
Property
Deceitful/
Manipulative
Serious Rule
Violation
Gang Related
Theft
Total ___ of 7
OTHER BEHAVIORIAL ISSUES
FREQUENCY
TYPE
N
D
W M N
HISTORY
30-60
days
3-12
months
Example of Last Episode/Notes
Sexually
Inappropriate-if yes
must give specifics
Personal Hygiene
Change
Runaway Behavior
Obsessions/
Compulsions
Jealousy
Attachment
Problems
Bedwetting
Fire Setting
Total _____ of 8
NBHS-PRTF Application Rev. 9/2013
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NBHS-PRTF
Resident Label:
PSYCHOSOCIAL STRESSORS
YES
NO
STRESSOR
EXAMPLE OF LAST EPISODE
Death/Loss of Significant Other
Rejection/Abandonment
Mental Illness in Family
Recent Physical Trauma
Major Illness of Family Member
Parental Separation/ Divorce
Remarriage of Parent
Family/Home Stressors
Out of Home Placement
Multiple Moves
Other
HOMCIDALITY INDICATORS
FREQUENCY
TYPE
N
D
W
M N
HISTORY
30-60
days
Example of Last Episode/Notes
3-12
months
Homicidal Thoughts
Use of Weapons
Anger/Rage
Threats/Aggression
Vindictive Behavior
Recent Physical
Violence
History of Physical
Violence
Total _____ of 7
NBHS-PRTF Application Rev. 9/2013
10
NBHS-PRTF
Resident Label:
Does client have access to weapons,
lethal medications, and/or other items
which could be use for self-harm in the
home?
YES
NO
(Weapons considered individual for said client’s history-see assessment history)
IF YES DOES THE GUARDIAN AGREE TO REMOVE AND OR SECURE WEAPONS? _______
PROTECTIVE FACTORS: _____________________________________________________________
____________________________________________________________________________________
ADDITIONAL COMMENTS: __________________________________________________________
DISCUSSION WITH: ______________________________________________________________
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
Place
YES
Specific Plan/Method
Outcome/Result
NO
Method
Outcome
If Yes, Details: ____________________________________________________________
TREATMENT HISTORY
TYPE
DATES
From
To
FACILITY
MD/THERAPIST
Reason for Treatment
NBHS-PRTF Application Rev. 9/2013
11
NBHS-PRTF
Resident Label:
CURRENT MEDICATION
Compliant
Medication
Dosage
Frequency
If not Compliant, Explain
YES
NO
Past Medication History (details of med and dosage):
Medical Problems/ Illness
Current
Past
Allergies (Food/Drug)
Developmental Delays
Approximate Height
Additional Medical Comments to include current tx and medications for
medical hx (be specific):
Approximate Weight
High Risk for Falls?
Sexually active: Yes or No If yes, date of last known sexual contact ______________
Sexual orientation: __________________________________
Birth Control Method:_____________________________________
NBHS-PRTF Application Rev. 9/2013
12
NBHS-PRTF
Resident Label:
SUBSTANCE ABUSE HISTORY
Age at
First Use
Drug Type
Current
Pattern/Frequency
Amount When Used
Last Use
Alcohol
Marijuana
Cocaine
Inhalant (aersol,Freon, gas)
Amphetamines (Ritalin,
Adderall)
Crystal Methamphetamine
Barbiturates (Valium)
Opiates (Heroine, Morphine,
Loratab)
Hallucinogenics (PCP, LSD,
Shrooms)
Ecstasy
Benzodiazepines (Xanax,
Ativan)
Cigarettes
Prescription Medication
OTC Drugs
WITHDRAWAL HISTORY
Tremors
Nausea/Vomiting
Weakness
Sweating
Cramps/Diarrhea
Blackouts
Fever
Irritability
Seizures
Chills
Tingling
Other:
FAMILY HISTORY OF SUBSTANCE ABUSE (Immediate Family Members):
Relationship to Client
Type of Substance(s) Used
Past Use
Current Use
NBHS-PRTF Application Rev. 9/2013
13
NBHS-PRTF
Resident Label:
STATEMENT OF APPLICATION FOR ADMISSION
Name of Person Completing this Application: __________________________________________
Relationship to Child: ________________________________ Date: _______________________
If , “Yes” , please provide name and explain: ____________________________________________
__________________________________________________________________________________
Signatures of Parent(s), Legal Guardians(s), or Agency Requesting Child’s Admission
_______________________________________________________________________________________________
Parent Signature
Date
_______________________________________________________________________________________________
Print Name
Relationship to Adolescent
_______________________________________________________________________________________________
Parent Signature
Date
_______________________________________________________________________________________________
Print Name
Relationship to Adolescent
_______________________________________________________________________________________________
Legal Guardian Signature
Date
_______________________________________________________________________________________________
Print Name
Relationship to Adolescent
_______________________________________________________________________________________________
Agency Representative Signature
Date
_______________________________________________________________________________________________
Print Name
Relationship to Adolescent
NBHS-PRTF Application Rev. 9/2013
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