ࡱ> q` KbjbjqPqP 4::+bbb86cle2h:v:v:v:v:v* d$ho .:v:v..:v:vNNN.|:v:vN.NNN:v&h &bN ǜ0Ny2yNyN\N~ގp....d@GG Resident Admission Application Applicant Identification Name:  FORMTEXT      Age:  FORMTEXT      DOB:  FORMTEXT      Address:  FORMTEXT      City:  FORMTEXT      State:  FORMTEXT      County:  FORMTEXT      Zip:  FORMTEXT      Phone #:  FORMTEXT      SS#:  FORMTEXT      Sex:  FORMDROPDOWN Race:  FORMDROPDOWN  Reason for Referral:  FORMTEXT       Client s MH Case Manager: FORMTEXT      Phone#: FORMTEXT       Funding Source:  FORMCHECKBOX  Medicaid  FORMCHECKBOX  NCHC  FORMCHECKBOX  IPRS  FORMCHECKBOX  Private Pay  FORMCHECKBOX  Other  Family/Guardian Information Parent/Guardian Name: FORMTEXT      Relationship: FORMDROPDOWN Address: FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT      Street/Apt.#CityStateZipPhone#: FORMTEXT      If guardian is not parent, parent s name: FORMTEXT       Person to contact in case of emergency (In order): Contact 1: Name: FORMTEXT      Relationship: FORMTEXT      Phone#: FORMTEXT      Contact 2: Name: FORMTEXT      Relationship: FORMTEXT      Phone#: FORMTEXT       Are there limitations on family visitation?  FORMCHECKBOX  Yes  FORMCHECKBOX  No - If yes please explain:  FORMTEXT        Education History Name of School(s) Attended: Most Recent two schools (1)  FORMTEXT       FORMTEXT      NameLocationDates of Enrollment: From  FORMTEXT      To  FORMTEXT      (2)  FORMTEXT       FORMTEXT      NameLocationDates of Enrollment: From  FORMTEXT      To  FORMTEXT       Please list any significant school behavioral concerns:  FORMTEXT        Residential History (Begin with most recent) 1) Name of Facility: FORMTEXT      Dates: from FORMTEXT       to  FORMTEXT      Type of Facility: FORMTEXT      Phone#: FORMTEXT      2) Name of Facility: FORMTEXT      Dates: from FORMTEXT       to  FORMTEXT      Type of Facility: FORMTEXT      Phone#: FORMTEXT      3) Name of Facility: FORMTEXT      Dates: from FORMTEXT       to  FORMTEXT      Type of Facility: FORMTEXT      Phone#: FORMTEXT        Mental Health Diagnosis Axis I FORMTEXT      Axis II FORMTEXT      Axis III FORMTEXT      Axis IV FORMTEXT      Axis V FORMTEXT       Any history of seizures:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Type and frequency of seizures:  FORMTEXT       Neurologist:  FORMTEXT       Phone #:  FORMTEXT       Allergies: Please list all allergies including any drug allergies:  FORMTEXT       Immunizations: A copy of your child s immunization record must be submitted. All immunizations must be up to date. Any major medical occurrences or concerns please list:  FORMTEXT       Medications NameReasonDosageTime(s) TakenPrescribing PhysicianPhoneDate Began FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       EXAMLAST EXAM DATEEXAMINERPHONEPhysical FORMTEXT       FORMTEXT       FORMTEXT      Pap Smear FORMTEXT       FORMTEXT       FORMTEXT      Dental FORMTEXT       FORMTEXT       FORMTEXT      Eye FORMTEXT       FORMTEXT       FORMTEXT      Speech & Hearing FORMTEXT       FORMTEXT       FORMTEXT      Orthopedic/Physical Therapy FORMTEXT       FORMTEXT       FORMTEXT      Neurological FORMTEXT       FORMTEXT       FORMTEXT      Other FORMTEXT       FORMTEXT       FORMTEXT       PHYSICIAN'S NAME  FORMTEXT      PHONE  FORMTEXT      ADDRESS  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT      DENTISTS NAME  FORMTEXT      PHONE  FORMTEXT       ADDRESS  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT      PHARMACISTS NAME  FORMTEXT      PHONE  FORMTEXT       ADDRESS  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT      SPECIALISTS NAME  FORMTEXT      SPECIALTY  FORMTEXT      PHONE  FORMTEXT       ADDRESS  FORMTEXT      CITY  FORMTEXT      STATE  FORMTEXT      ZIP  FORMTEXT       APPLICANTS STRENGTHS / CAPABILITIES:  FORMTEXT      PREFERRED ITEMS:  FORMTEXT       INTERESTS/HOBBIES:  FORMTEXT      NECESSARY SUPPORTS FOR APPLICANT:  FORMTEXT      DOES APPLICANT HAVE ANY SERIOUS BEHAVIOR PROBLEMS?  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jhL`B*CJUaJph,jՄhL`h/[B*CJUaJph40\0^0`000001z9kd$$If(0`'0*0*4 (aX9kd.$$If(0`'0*0*4 (aX($1$7$8$H$Ifgd35 1 1111111111111111111222س|d||L||>h>5B*CJaJph/jψhL`h/[5B*CJUaJph/jYhL`h/[5B*CJUaJph hL`hL`5B*CJaJph)jhL`hL`5B*CJUaJph hL`h>5B*CJaJphh#h>B*CJaJph+jhL`B*CJUaJmHnHphu jhL`B*CJUaJph,jxhL`h/[B*CJUaJph112<2>222zff$($1$7$8$H$Ifa$gdL`9kd$$If(0`'0*0*4 (aX($1$7$8$H$Ifgd359kd$$If(0`'0*0*4 (aX2*2,2.282:2<2>2222222 33*3,3.303T3V3r3t3v33˵˦oXA,jhL`h/[B*CJUaJph,j$hL`h/[B*CJUaJph,jhL`h/[B*CJUaJph hL`h>5B*CJaJphh#h>B*CJaJphhL`hL`B*CJaJph+jhL`B*CJUaJmHnHphu jhL`B*CJUaJph,jEhL`h/[B*CJUaJphhL`B*CJaJph22 3 3R3T333($1$7$8$H$Ifgd35Ikd&$$If(0`'0*  0*4 (aXp 3333J L   ($1$7$8$H$Ifgd35_kd$$If(4F0 F`' P0*    4 (aX333333334    " L N j l n p          !!!!b!d!!Ӽߺӣӌu^,jhL`h/[B*CJUaJph,jhL`h/[B*CJUaJph,jhL`h/[B*CJUaJph,jhL`h/[B*CJUaJphU,jhL`h/[B*CJUaJphhL`B*CJaJph jhL`B*CJUaJphh#h>B*CJaJph" FORMCHECKBOX  Has temper tantrums  FORMCHECKBOX  Runs away  FORMCHECKBOX  Threatens physical harm to self  FORMCHECKBOX  Displays inappropriate sexual behavior  FORMCHECKBOX  Is severely withdrawn  FORMCHECKBOX  Does physical harm to self  FORMCHECKBOX  Steals  FORMCHECKBOX  Is hyperactive  FORMCHECKBOX  Attempts or threatens suicide  FORMCHECKBOX  Attempts or commits arson  FORMCHECKBOX  Deliberately provokes others Please describe checked items, and any other inappropriate behaviors exhibited by the applicant, giving details of how each has been a problem and what has been done to try to change these behaviors and what the results have been. (Attach copies of current and past Behavior Plans).  FORMTEXT       Is applicant presently receiving psychological/psychiatric services?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Therapist/counselor name:  FORMTEXT       Phone#:  FORMTEXT       Address: FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Length of time in service? FORMTEXT      How often? FORMTEXT       Is there a family history of Developmental or Psychiatric Disabilities?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Please Describe:  FORMTEXT       Does applicant have a court record?  FORMCHECKBOX  Yes  FORMCHECKBOX  No County:  FORMTEXT       Offenses:  FORMTEXT       Please attach a copy of any court orders mandating services and/or conditions. Additional Comments: (applicant s attitude toward handicap, applicant s personal goals, family s attitude toward handicap and/or placement, etc& )  FORMTEXT       Does client know this application is being submitted?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Name of person submitting application:  FORMTEXT       Signature of person completing application:_______________________________________ Date:________ Relationship to client:  FORMTEXT       Phone#:  FORMTEXT        FORMTEXT  DATE \@ "MMMM d, yyyy" October 20, 2007October 20, 2007 Dear Provider, First of all, I would like to take this opportunity to personally thank you for considering CBAY, Inc. to work with your consumer to provide their residential treatment needs. Prior to the admission acceptance of your client, there are several things that will need to be provided or added to their PCP to ensure that they receive the very best in care. The following will outline these needs.  FORMCHECKBOX Ensure that the PCP has been updated to reflect CBAY as the residential provider with appropriate interventions for my staff to perform as determined by the treatment team. This will include ensuring that the goals are derived from Observations/Needs portion of the PCP which came from the Diagnostic Assessment indicating those needs. Also, please ensure that the interventions listed for the residential provider are individualized for the client referred and that they are not generic  canned interventions. FORMCHECKBOX That the PCP crisis plan is complete and up to date meeting all requirements by the LME and DMA. FORMCHECKBOX That we receive the most recent copy of the Diagnostic Assessment, Psychological Evaluation, NCTOPPS, etc. FORMCHECKBOX That we receive the most up to date list of medications as well as prescribing physician information and next scheduled appointment. There should also be ample medications available to get through to the next scheduled appointment. Should there not be at least a two week supply of meds, we ask that arrangements already be made for a med review for refill prescriptions. FORMCHECKBOX That the consumer is receiving at least individual therapy on a weekly basis and the next appointment time has been scheduled along with Therapist name and contact information. Also, all clients in residential placement should also be involved in family therapy to assist with reunification efforts. FORMCHECKBOX That we receive a copy of the Birth Certificate or court order of legal guardianship, a copy of the social security card and the most recent Medicaid or NCHC Insurance card upon admission to the program. FORMCHECKBOX That in the intervention of the PCP (if determined appropriate by the treatment team) it be added that Consumer may be transported to school, appointments, etc. by one staff when the consumer is being transported without other consumers present. FORMCHECKBOX That there is a current authorization for Level III residential services available on Provider Connect (if Medicaid) prior to scheduling intake. FORMCHECKBOX The Residential Application for Services has been completed and forwarded to CBAY with all supporting documentation. FORMCHECKBOX A complete list including address and telephone number of all persons or entities that we will need to obtain an Authorization for Use and Disclosure for.  The above requested information will greatly assist us in determining if your client is suitable for our program and if our services are able to meet their needs. Male FacilityFemale FacilityCBAY  Limerick House 815 Limerick Drive Dallas, NC 28034 (704) 922-1404 Facility ID#: 6603777CBAY  Hickory Creek House 151 Hickory Creek Drive Gastonia, NC 28054 (704) 810-0048 Facility ID#: 6603472      CBAY, Incorporated Community Based Alternatives for Youth, Inc. CBAY, Inc. f& 175 W. 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