NORTHLAKE YOUTH ACADEMY Psychiatric Residential Treatment Facility Hwy. 190 Mandeville, Louisiana Phone: Fax:

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1 NORTHLAKE YOUTH ACADEMY Psychiatric Residential Treatment Facility Hwy. 190 Mandeville, Louisiana Phone: Fax: 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

2 Voluntary Placement by Family Voluntary Placement by State Agency Resident Demographics Resident s First Name MI Last Name DOB Age Sex Race SSN Weight Height Eye Color Hair Color Address City State Zip County Religious Preference 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 DOB SSN Group Number Policy Number Employer Secondary Insurance Company Phone # Subscriber DOB SSN Group Number Policy Number Employer Primary Care Physician Name of Practice City/State Phone NBHS-PRTF Application Rev. 9/2013 2

3 Parent / Legal Guardian Information Parent/Guardian #1 DOB SSN Relationship Address Phone(s) Employer Address Work Phone Parent/Guardian #2 DOB SSN Relationship Address Phone(s) Employer Address Work Phone Biological Mother s Name Biological Father s Name Emergency Contact 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 3

4 DHH/DCFS Custody Date Placed Reason for Placement History of Emotional / Physical / Sexual Abuse or Neglect Type of Abuse Abuser/ Relationship to Client Date/ Age Abused Reported (Yes or No) Founded or Unfounded Yes No Is client a sexual perpetrator? If Yes, explain : *Any/all abuse (disclosed during assessment) must be reported by the assessor within 24 hours to the DCFS Call LA-KIDS ( ) toll free 24 hours a day, 365 a year and documented below: Staff Initials Date Reported Time Reported to appropriate staff? LEGAL 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 Is Client Court Ordered to TX? Does Client have upcoming court date? Has Client ever been arrested? Phone # Parish If Yes, Order Date: If Yes, Court Date: Where: If Yes, List charges: Has Client ever been placed in detention? If Yes: Date Where Reason NBHS-PRTF Application Rev. 9/2013 4

5 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? If Yes, YES NO When Results of Test Psychological ADHD/ADD FSIQ Score: Learning Disability Yes No Is Client Currently in Resource/ Special Ed? Current Grade Level: Above Average Average Below Average Additional Educational Comments: NBHS-PRTF Application Rev. 9/2013 5

6 Behavioral/Social History DEPRESSION Example of Last Episode Depressed, Sad Hopeless Loss of Interest Appetite Change Insomnia Decreased Energy Sense of Worthlessness Somatic Complaints Isolative Mood Swings PSYCHOSIS Total of 9 Example of Last Episode Delusions Hallucinations Disorganized Speech Disorganized Behavior Paranoia Catatonic Behavior Total of 6 NBHS-PRTF Application Rev. 9/2013 6

7 MANIA 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 ANXIETY Total of 10 Example of Last Episode Excessive Worry Restlessness Muscle Tension Panic Attacks Easily Fatigued Total of 5 NBHS-PRTF Application Rev. 9/2013 7

8 IMPULSIVITY 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 OPPOSITIONAL DEFIANT Total of 10 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 8

9 CONDUCT ISSUES Example of Last Episode/Notes Aggressive to People Aggressive to animals Destruction of Property Deceitful/ Manipulative Serious Rule Violation Gang Related Theft OTHER BEHAVIORIAL ISSUES Total of 7 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 9

10 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 Example of Last Episode/Notes 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/

11 Does client have access to weapons, lethal medications, and/or other items which could be use for self-harm in the home? YES (Weapons considered individual for said client s history-see assessment history) NO IF YES DOES THE GUARDIAN AGREE TO REMOVE AND OR SECURE WEAPONS? PROTECTIVE FACTORS: ADDITIONAL COMMENTS: DISCUSSION WITH: OF SUICIDAL/HOMICIDAL IDEATIONS/GESTURES/ATTEMPS Dates or Age SI/HI SG/HG SA/HA Specific Plan/Method Outcome/Result OF ANY SPECIAL TREATMENT PROCEDURES WHILE IN OTHER PLACEMENTS? YES NO Date Place Method Outcome If Yes, Details: TREATMENT DATES FACILITY MD/THERAPIST Reason for Treatment From To NBHS-PRTF Application Rev. 9/

12 CURRENT MEDICATION Medication Dosage Frequency YES Compliant NO If not Compliant, Explain Past Medication History (details of med and dosage): Medical Problems/ Illness Current Past Allergies (Food/Drug) Developmental Delays Approximate Height Approximate Weight High Risk for Falls? Additional Medical Comments to include current tx and medications for medical hx (be specific): Sexually active: Yes or No If yes, date of last known sexual contact Sexual orientation: Birth Control Method: NBHS-PRTF Application Rev. 9/

13 SUBSTANCE ABUSE Drug Type Age at First Use 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 Tremors Nausea/Vomiting Weakness Sweating Cramps/Diarrhea Blackouts Fever Irritability Seizures Chills Tingling Other: FAMILY OF SUBSTANCE ABUSE (Immediate Family Members): Relationship to Client Type of Substance(s) Used Past Use Current Use NBHS-PRTF Application Rev. 9/

14 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/

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