Admissions Instructions

Transcription

1 Admissions Instructions Attached please find an application for admission. 1. Please complete the application. 2. Attach any psychological evaluations, hospital reports, and discharge reports from previous programs. 3. Overnight a $ non-refundable application fee to PO Box , Murray, UT (made payable to CERTS). 4. Fax OR mail the application to the La Europa Academy. 5. The Clinical Director will evaluate the application and either the Admission Director or the Clinical Director will inform you by phone if your daughter has been accepted for admission. 6. Once your daughter has been accepted into La Europa Academy program, upon admission you must bring a Certified Cashier s Check for $ , which includes one month s tuition in the amount of $9, and $1,500 for your daughter s trust account. 7. You will receive a pre-admission packet with the Treatment Contract, and a multitude of forms to be signed and brought with you to admission. 8. Your pre-admission packet will also include a packing list of items for your daughter. 9. If your daughter is to be brought to the facility by a transport company, our Director of Operations can provide you with the names of several transport companies. La Europa Academy Contact Information Nora Urbanelli Courtney Merrill Richard Long Director Clinical Director Program Director David Mayeski Melissa Negrete Admissions Director Director of Operations Rev. 07/01/07

2 Application for Enrollment STUDENT INFORMATION Full Legal Name DOB Age Current Grade level Home Address Home phone # Social Security # Citizenship Race/Ethnicity Religious preference Ht Wt PARENT/LEGAL GUARDIAN INFORMATION Are parents divorced? Yes No Who has legal custody? Who has physical custody? May the non-custodial parent access information about your daughter s treatment? Yes No If parents are divorced, please provide a copy of legal custodial papers Biological/Adoptive Father Will this parent participate in student s treatment at La Europa Academy? Yes No Circle all that apply: Phone calls Letters Family therapy Parent Weekends Full Legal Name SS # Home Address Home Phone Cell/Pager Fax Business Address Occupation Business Phone Business Cell Business Fax Education Annual Income $ 2

3 Biological /Adoptive Mother Will this parent participate in student s treatment at La Europa Academy? Yes No Circle all that apply: Phone calls Letters Family therapy Parent Weekends Full Legal Name SS # Home Address Home Phone Cell/Pager Fax Business Address Occupation Business Phone Business Cell Business Fax Education Annual Income $ Stepfather Will this parent participate in student s treatment at La Europa Academy? Yes No Circle all that apply: Phone calls Letters Family therapy Parent Weekends Full Legal Name SS # Home Address Home Phone Cell/Pager Fax Business Address Occupation Business Phone Business Cell Business Fax Education Annual Income $ Stepmother Will this parent participate in student s treatment at La Europa Academy? Yes No Circle all that apply: Phone calls Letters Family therapy Parent Weekends Full Legal Name SS # Home Address Home Phone Cell/Pager Fax Business Address Occupation Business Phone Business Cell Business Fax Education Annual Income $ 3

4 INSURANCE INFORMATION Primary Insurance Company s name Insurance mailing address City State Zip Insurance phone Effective Date of Coverage Office Visit CoPay $ Policy/ID (Cert) # Group # Plan Name or # Relationship of Patient to Policy Holder: Self Dependent Child ONLY complete Policy Holder information if different from patient. Policy Holder s Name Policy Holder s Address Last First Middle City State Zip Telephone Sex: M F Date of Birth Social Security # Secondary Insurance Company s name Insurance mailing address City: State Zip Insurance phone Effective Date of Coverage Office Visit CoPay $ Policy/ID (Cert) # Group # Plan Name or # Relationship of Patient to Policy Holder: Self Dependent Child ONLY complete Policy Holder information if different from patient. Policy Holder s Name Policy Holder s Address Last First Middle City State Zip Telephone Sex: M F Date of Birth Social Security # 4

5 EMERGENCY CONTACT In case of emergency if I/we cannot be reached La Europa Academy may contact the following individual: Name Relationship Address Home phone Work phone REFERRAL/PROFESSIONAL CONSULTANT INFORMATION How did you hear about us? Name of Referral Source Relationship Work phone Cell phone MENTAL HEALTH TREATMENT PROFESSIONALS Please check all types of mental health treatment your daughter/family has received: Outpatient: Individual Group Family therapy Mental health problems and/or Drug problems Day treatment for: Mental health problems and/or Drug problems Short term hospital stay for: Mental health problems Inpatient treatment for: Mental health problems and/or Drug problems Residential/wilderness treatment for: Mental health problems and/or Drug problems List all mental health professionals your daughter has seen on an outpatient basis in the past two years. Name Title Address Phone Dates of service Services: Individual Family therapy Psych testing Meds Eating disorder treatment Substance abuse treatment 5

6 Name Title Address Phone Dates of service Services: Individual Family therapy Psych testing Meds Eating disorder treatment Substance abuse treatment Name Title Address Phone Dates of service Services: Individual Family therapy Psych testing Meds Eating disorder treatment Substance abuse treatment Has your daughter ever been hospitalized for psychiatric, psychological, eating disorders or substance abuse reasons? Please give details: From/To Hospital Issues addressed Describe how your daughter has failed to benefit from mental and behavioral health services provided in an environment less restrictive than a CERTS program: Describe how your daughter s current problems present a safety issue for her, if she remains in her home or community: 6

7 OUT OF HOME PLACEMENTS List any out of home placements (eg: foster care, RTC s, wilderness programs, boarding schools etc) Name of placement Contact person Dates of placement Reason for placement Address Phone Name of placement Contact person Reason for placement Address Dates of placement Phone Name of placement Contact person Reason for placement Address Dates of placement Phone If your daughter has been in any psychiatric hospitals, inpatient treatment programs, residential treatment programs, wilderness programs or has received any outpatient mental health treatment, please attach a copy of treatment summaries, discharge reports or psychological assessments and evaluations to this application. 7

8 SCHOOL Current Grade level Name and address of most recent school attended: School Address Please describe your daughter s attitude towards school and how she is performing: Has your daughter been suspended/expelled from school or held back a grade? Yes Explanation: No Is your daughter intelligent, but unmotivated academically? Yes No Explanation: Has your daughter been in resource or special education classes? Yes No Has your daughter ever been diagnosed with learning disorders? Yes No Explanation: Does your daughter have any disabilities that would prevent her from completing reading and writing assignments designed for adolescents of average intelligence? Yes No Explanation: What are your educational goals for your daughter while she is at her CERTS program? What are your educational goals for your daughter after she graduates from her CERTS program? 8

9 Describe any history of depressive features, mood swings or periods of isolation: If your daughter has ever been physically or sexually abused, please provide details: Describe any other major traumatic changes or events in your daughter s life (death, illness, etc): If your daughter has ever run away from home, please provide details: If your daughter self-harms (cutting on herself, burning skin with cigarettes, etc) please provide details (how long, where on her body, when it happens, etc): Does your daughter engage in excessive or inappropriate computer/video games, telephone or TV use? Yes No Explanation: 9

10 Does your daughter have any medical/physical problems associated with eating behaviors? Yes Explanation: No If your daughter is admitted to a CERTS program with signs and symptoms of a mild eating disorder, she must be followed by our outpatient physician as well as by our consulting dietitian. Costs for these services will be in addition to monthly tuition. Does your daughter avoid a complete food group when eating? (eg: meat, fruit, vegetables, dairy, etc) Yes No Explanation: Does your daughter have any dietary restrictions or special dietary needs? Yes Explanation: No If your daughter has food allergies, food avoidance, or special dietary needs she must receive an in-depth nutritional assessment by our consulting dietitian. Costs for these services will be in addition to monthly tuition. Yes. While my daughter does not have a diagnosed eating disorder, food allergies or food avoidance, I want her to meet with the consulting dietician. Please list food allergies: DRUG/ALCOHOL USE Has your daughter ever used drugs and/or alcohol? Yes No Describe type if known and the amount and length of use: Will your daughter need to be detoxed? Yes No Has your daughter had treatment for substance abuse? Yes No Has your daughter experienced a relapse since treatment? Yes No If yes, how many times, length of relapses, drugs used: 10

11 Does your daughter smoke cigarettes? Yes No Is there any history of alcohol or drug problems with any family members, including extended family members? If your daughter has been treated for chemical dependency, please list her therapist/treatment facility on page three of this application. Please request a copy of her treatment summary or discharge report and attach to this application. LEGAL CONCERNS Has your daughter ever been arrested? Yes No Explanation: Has she ever been convicted of a felony? Yes No Does she have any felony charges pending? Yes No Is your daughter currently on probation? Yes No End date P O Officer s name Address: Home Phone # Fax # Cell # SOCIAL SKILLS SUPPORT NETWORK Has your daughter changed friends recently? Yes No Explanation: Please describe your daughter s relationships with her peers: Please list your daughter s interests, positive qualities, talents and accomplishments: 11

12 Please describe her involvement with religious/spiritual organizations, groups, and clubs: FAMILY With whom does your daughter live? Name Age Relationship Please describe your daughter s relationship with family members: Dad: Mom: Step-Dad: Step-Mom: Siblings: Is your daughter adopted? Yes No What age? Were there any special circumstances? Yes No Explanation: Does adoption appear to be an issue? Yes No Explanation: 12

13 If known, describe marriage history of biological parents: Describe your daughter s reaction to any divorce or separation of parents: If your daughter does not live with her biological family, what is her relationship with the biological family, (including communication, visits, etc)? Is there any significant history of psychiatric or emotional problems with any family members (including extended family members)? What has the effect of your daughter s problems been on your family? Are there unique or unusual family dynamics that CERTS should take into consideration when planning and implementing treatment with your daughter? Yes No Explanation: Where do you anticipate your daughter living when she graduates from her CERTS program? 13

14 DEVELOPMENTAL HISTORY Please describe your pregnancy with your daughter (ie: normal, complications, etc): Did your daughter achieve developmental tasks on time (eg: walking, talking etc)? Yes Describe the personality of your daughter at the following three stages: Birth to 5 years: No 6 years to 11 years: 12 years to present: Does your daughter have any physical limitations? Yes No Explanation: MENSTRUATION/SEXUAL BEHAVIOR Date of last menstrual period: No menstrual periods to date Severe pain or cramps Severe mood change History of missing periods Sexually active History of STD s Number of times pregnant Number of times miscarried or aborted Pregnant now ***Must provide a pregnancy test prior to admission*** 14

15 MEDICAL/PHYSICAL Please fill out Medical History Form, which is included in the Pre-Admission Medical Packet. Will your daughter need ongoing medical care for any physical conditions while she is enrolled at her CERTS program? Yes No Explanation: MEDICATIONS If your daughter is presently taking any prescribed medication for any medical condition please complete below: Medical Condition Name of Medication Dosage/day Please list all psychotropic medications your daughter has taken in the past and there effects: Name of Medication Effect Please list medication that has been successful for immediate family members who are being treated for any psychiatric reason, including medication for sleep: 15

16 Please list medication related goals that you have for your daughter: Please submit your application to the following address LA EUROPA ACADEMY US Mail: P O Box , Murray, Utah Fed Ex or UPS: 1220 East Vine Street, Murray, Utah (Salt Lake City) Fax number: (801) Phone number: (801) I/we do hereby make application for our daughter to be admitted to a CERTS program. Parent/Guardian signature Date Parent/Guardian signature Date 16

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