Orchard Place PMIC Application

Orchard Place Campus Access Form

Please complete the following information to the best of your ability. This information is critical to the treatment that your child and family will receive. Full and accurate information is necessary.
Person filling out form:   Your First Name*   Your Last Name*
Relationship to the child:   Relationship*
Date form completed:   Date*
Please note, we do prefer a direct caregiver/parent/guardian completes this application.

The following information is very important in the referral process.

Indicate all services child is currently receiving or has received. These providers will be contacted for records. This is an important step in reviewing referrals. Please tab through provider list to ensure all are filled out.
Include Provider Name, Agency/Organization Name, and Phone Number.*
Include All Past Placements and Year:
Additional Providers (include phone number or email):

Custody*
Please explain any custody situations (including who has physical custody, legal custody, visitation schedules, TPRs, etc.) Please attach legal documentation if you have it to the end of this application.*
Is your child adopted?*

YesNo
If yes, at what age?
Please list important information about the birth family:
Household 1:*
Parent 1:*
Parent 2:
Does your child have another parent/guardian living separately from you? (Please fill this out even if they are not actively involved.)

YesNo
Household 2 (if parents/guardians are separated):
Parent 3:
Parent 4:
Military History/ Service Record of the parents:
Are there other caretakers for the child?

Sibling information

Others in the home

Family Stressors and Mental Health History. Select all that apply and explain below.
For each identified item, please describe:
Please describe the mental health history of other family members. Indicate the person and relationship to the child.*

History of Trauma for your child: (select all that apply and describe below)
Explain above here:*
If child has any physical or sexual abuse, please indicate by whom abuse occured.
If the child has contact with a person who is a sex offender, please list that name here.
If the child has a no contact order of any kind, describe below.

Who is recommending Orchard Place Campus for your child? *
Reason for Referral:
Description of behavioral concerns within the last year. (Please describe check boxes)*

Please list your child's current psychiatric diagnosis:*
Please list any current psychiatric medication and the response to that medication. *
Please list any previous medication and reason for discontinuation.
Has your child ever been restrained in a hospital, in a crisis stabilization unit, school, home or other setting? If yes, why and what was the child's response? *
Are you aware of any medical conditions or physical disabilities that may cause problems during a physical restraint? If yes, explain below: *
Are there any nutritional concerns or dietary needs? If yes, explain below:*

Has your child ever been suspended from school? *
If yes, what grade and what were the behaviors that led to the child being suspended?
Other schools attended in the last 2 years:
Problems in school? Learning or behavioral? Describe in detail below with grade:*
Has your child been employed? *
Career interests?*

Substance use*

Rows	Yes, No, Unknown	Comments
Childhood exposure to substance use?
Child has history of substance use?
Previous substance abuse services?

If other, write here:
Description of Substance use and/or Substance abuse services, including other involvement with drugs, dealing drugs etc. (include age of use)*
Has your child experienced legal, behavioral or social consequences from the use of alcohol or drugs? *

IMPORTANT

After signing and continuing, you will be directed to another link that will have final documents for submission. Those documents must be completed to consider application complete.
Signature- To my knowledge, the above information is complete and accurate. I understand that failure to provide information could result in unsuccessful treatment.

Clear
Should be Empty:

Orchard Place Campus Access Form