Youth Alternative Home Association

YOUTH ALTERNATIVE HOME ASSOCIATION

ADMISSION FORM

Date of placement: ______

Name of Person Placing Resident: ______

Name Agency of Person Placing Resident (Specify which Police Department, or Sheriff, or Patrolman,

etc):______

______

Last Name, FirstMiddleAKAClient No.

______

Physical address,City, State ZipPhone

______

Mailing addressCity State Zip

______

Sex Race Age DOBSSN

______

HeightWeightHairEyesattach photo

______

Date of last placementPlace of birth

Name, address and phone number of foster family (if applicable)______

Primary reason for placement: ______

Childs Immediate Needs: -______

______

PARENTS -

BioMother:______Address: ______

Phone: ______

Employment:______Work Phone:______

BioFather: ______Address: ______

Phone: ______

Employment:______Work Phone:______

StepMother: ______Address: ______

Phone: ______

Employment:______Work Phone:______

StepFather: ______Address: ______

Phone: ______

Employment:______Work Phone:______

? Significant other of parents:______

______

In case of an emergency, contact: ______

Other agency involvement (cited by law enforcement?) / prior placements: ______

______

Special concerns/restrictions, medical conditions/allergies: ______

Siblings and/or other household members (please include age & relationship to resident):

______

SCHOOL:

Name and address of school most recently attended: ______

Recent grades:______

Attendance:______

Behavior Problems:______

Recent Suspensions: ______

Special Services: ______

Other:______

Religious preference: ______

The Youth Alternative Home Association does not discriminate in regard to race, color, national origin, religious creed, or disabilities.

______

Intake WorkerDate

(FORMS DISK 3, ADMIS.DOC)

YOUTH ALTERNATIVE HOME ASSOCIATION

PERSONAL MEDICAL DATA FORM

Name______Client#______

Date of Placement______

Date of Birth______

Current Physician:______

Date of Last Exam:______By:______

Medical Coverage: (check one)

_____ Private Insurance _____ Title IXX

_____ Other DFS Coverage _____ Unknown

Any Known Medication Allergies:______

Any other Allergies: ______

Any Current Medical Problems:______

Any Current Medications:______

Dose:______Date & Time of Last Dose:______

Prescribed By:______

Any Distinguishing Features (birth marks, tattoo’s, scars):______

______

Number of piercing and where (tongue?):______

Any Previous Surgeries & Date:______

Are Immunizations Current: Yes ______No______If no, what is needed?

______

Have you ever tested positve for Tuberculosis (circle) YES NO

Have you ever tested positve for Hepatitis (circle) YES NO

Any Skin Rashes/Irritations:______

Any Episodes of seizure activity:______

Any Episode of Respiratory Difficulties:______

Any Episode of Stress-Related Illness:______

Have you had the usual childhood illnesses: Yes______No______

If No, list those not contacted yet?______

List any current health related concerns:______

List any past major medical concerns:______

List any past medications taken:______

Describe, if any, drug and alcohol use-list type and frequency:

Past types of drugs/alcohol:______

Frequency of drugs: ______

Present type of drugs/alcohol: ______

How often recently: ______

Do you use tobacco products: yes no What kind ______

For how long have you used: ______

Frequency of use : ______

Describe the following:

Sleeping habits (circle): Light Heavy sleeper Walks in sleep Talks in sleep Normal

Eating habits (circle): Light Heavy eater Picky Normal

Hygiene skills:______

Bowel habits: Constipated Diarrhea Normal

Females: Is your cycle regular? YES NO If no, explain ______

When was your last period? ______

FYI: Feminine products are kept in storage closet and will be distributed by female staff.

Vision: Wear Glasses:______Contacts:______

Date of last exam:______By:______

Comments:______

Hearing Adequate: Yes______No______Comments:______

______

Dental: Date of last exam:______By:______

Any Additional Information Pertinent to Health Care:______

______

(FORMS DISK 3, MED.DOC)

YOUTH ALTERNATIVE HOME ASSOCIATION

PARENT(S) CONTRACT

I, ______, parent(s) of ______, YAHA resident, understand and have had explained all the policies, rules and procedures outlined in the Resident Orientation Packet that I had questions and concerns regarding. I understand that the length of time a resident spends at the YAHA Group Home is determined by the individuals treatment plan and his/her progression. The emphasis early in the program is for the resident to adjust to the structure and expectations of the program, and to develop relationships with staff and peers. This is frequently a time of testing the limits, and wanting to be “rescued”. This can also be a trying time for the parents as they sometimes feel guilty and responsible for their child’s unhappiness. It is important to understand that this adjustment period must be tolerated and worked through; that the amount of time it takes varies for each individual; and that at some point, a resident makes a commitment to work through the program rather than struggling against it. Once that happens, the resident begins to progress through the level system and proceeds towards completion and discharge.

I, ______, understand the importance of working closely with YAHA in supporting my adolescent's treatment. I am expected to keep YAHA Staff informed of any situation or event happening within the family that may be of significance and/or effect my adolescent. The treatment goal is to provide necessary intervention to enable my adolescent to return to and remain in your or their home as soon as possible. I will cooperate and support YAHA’s efforts in my adolescent's treatment to facilitate this process.

I, ______, agree to abide by any Court Orders that are currently in effect or may become in effect, and I understand that YAHA will assist me with these if needed (i.e.: counseling sessions, parenting classes, etc.). I further understand that at some point my adolescents treatment plan may be contingent on my participation in the YAHA Program and Court Ordered requirements.

I will contact the YAHA Group Home with any further questions or clarification regarding the program.

If your child is 16 years of age or older – do they have a Birth Certificate and Social Security CardYor N If not, you will be required to obtain/order these documents while your child is in YAHA.

______

PARENTDATE

______

WITNESSDATE

YAHA is interested in your concerns regarding your youth. Your suggestions assist the Group Home in determining what treatment is most appropriate for your child.

Please list the issues you feel are important for your child to explore while in the YAHA Program. Thank you for your information.

YOUTH ALTERNATIVE HOME ASSOCIATION

PERMISSION TO TREAT

I, ______, hereby verify that ______

(Custodian) (Resident)

is in legal custody of ______. I verify as legal custodian that it

(Agency of worker)

is in the best interest of ______to be placed with the Youth

(Resident)

Alternative Home Association for appropriate placement in a foster home or group home setting.

I hereby grant my permission to have ______vaccinated and/or given

(Resident)

emergency treatment, be it medical, surgical, emergency evacuation, psychological or otherwise, as may be deemed expedient by the staff, foster parents and/or physician selected by the Youth Alternative Home Association.

I understand that I will be informed of all treatment as appropriate. In the event of an emergency, I will be informed as soon as possible.

Signature: ______Law Enforcement Date: ______

(Custodian)Relationship/Agency

Witness: ______Date: ______

Signature: ______Parent/Guardian Date: ______

(Custodian)Relationship/Agency

Witness: ______Date: ______

Signature: ______Dept of Family ServicesDate: ______

(Custodian)Relationship/Agency

Witness: ______Date: ______

YOUTH ALTERNATIVE HOME ASSOCIATION

RESIDENT’S SAFETY PLAN

Resident’s Name: ______Date of Birth: ______

Describe any of the following safety issues that the youth may have while in placement and a plan to address the issue.

1. History or Likelihood of Running Away (brief description or NA): ______.

High- Take shoes and coat. Resident will sleep in the living room to be monitored. Have resident complete a feelings chart and review with staff. Notify the Department of Family Services.

Moderate- Take shoes and coat. Have resident complete a feelings chart and review with staff.

If staff determines that resident may not run away, then give resident a room.

Low- Resident may keep shoes and coat. Resident can be placed in a room.

2. History or Likelihood of Suicidal Behavior (brief description or NA): ______.

High- Take shoes and coat. Confiscate all belts, sharp objects, etc., from the resident’s possession. Resident will sleep in the living room to be monitored more closely. Notify mental health. Notify DFS. Resident will sign a Stay-Alive Contract. Resident will fill out a feelings chart and review with staff.

Moderate-Take shoes and coat. Confiscate all belts, sharp objects, etc., from the resident’s possession. Resident will sleep in the living room to be monitored more closely. Resident will sign a Stay-Alive Contract. Resident will fill out a feelings chart and review with staff.

Low- Confiscate all belts until Level 1 achievement. Resident may keep shoes and coat. Resident can be placed in a room.

3. History or Likelihood of Self-Mutilation (brief description or NA): ______.

Moderate- Take shoes and coat. Confiscate all belts, sharp objects, etc., from the resident’s possession. Resident will sleep in the living room to be monitored more closely. Resident will sign a Stay-Alive Contract. Resident will fill out a feelings chart and review with staff.

Low- Resident may keep shoes and coat. Resident can be placed in a room. Tacks, razors, scissors, fingernail items, glass, etc. are never to be kept in any bedrooms whatsoever.

4. Life Threatening Illnesses or Allergies (brief description or NA): ______.

High- Get all information needed from placing agency, parents, doctor, etc. regarding the illness or allergy etc. Have placing agency, parents, doctor, etc. explain the necessary action or plan taken if an incident occurs.

Moderate- Get all information needed from placing agency, parents, doctor, etc. regarding the illness or allergy etc. Have placing agency, parents, doctor, etc. explain the necessary action or plan taken if an incident occurs.

Low-

5. Risk of Harm from Family Members of Others While in Placement: ______.

High- Anyone who may pose a threat to the resident will not be allowed on the YAHA premises. Notify DFS and the police department to inform them of the situation and/or if the above named people come to the YAHA facility. Alarms will need to be set at all times while the resident is in YAHA. Place the information in the daily log and on the Chrono-Bio.

Moderate- Anyone who may pose a threat to the resident will not be allowed on the YAHA premises. Notify DFS and the police department to inform them of the situation and if the above named people come to the YAHA facility.

Low-

6. Physical Limitations (brief description or NA): ______.

High- Get all information needed from placing agency, parents, doctor, etc. regarding the limitation. Accommodate the resident as much as possible (in front room, etc.).

Moderate- Get all information needed from placing agency, parents, doctor, etc. regarding the limitation. Accommodate the resident as much as possible (in front room, etc.).

Low

7. Other (brief description or NA): ______.

High Get all information needed from placing agency, parents, doctor, etc., regarding the particular situation. Contact supervisor if necessary.

Moderate (plan is same as “High” rating).

Low

______

Parent/Guardian/Caseworker/Law EnforcementDate

______

StaffDate (Forms disk 6 / safety plan)

YOUTH ALTERNATIVE HOME ASSOCIATION

PERMISSION FOR PSYCHOTROPIC MEDICATION

I, ______, hereby grant my

(Parent/Legal guardian)

Permission to have ______, be given

(Resident)

Psychotropic medications as prescribed by a Licensed Physician. I understand that these medications are for the treatment of mental illness and will only be used when prescribed by a licensed physician when other less restrictive alternatives have proven to be ineffective or are diagnostically eliminated from consideration.

Signature ______Date______

(Parent/Legal guardian)

Witness ______Date______

Attachment B

(Forms Disc. #1/ perm. Meds.)

YOUTH ALTERNATIVE HOME ASSOCIATION

PERMISSION FOR MEDICATIONS

I understand that ______may be given medications for the treatment of minor illness and/or injury while a resident of the Youth Alternative Home. Medications may be prescribed by a Licensed Physician or an over the counter medication. Medications will be given as directed on the package label.

Signature______Date______

(Parent/Legal Guardian)

Witness______Date______

YOUTH ALTERNATIVE HOME ASSOCIATION

CLIENT INFORMATION REQUEST OR RELEASE

Name of client: ______, DOB ______

I, the client, or the client’s parent/legal guardian, hereby authorize Youth Alternative Home Association, P.O. Box 943, Evanston, Wyoming 82931, to obtain or release information for treatment or from my chart as specified below:

Information will be: ______released to______obtained from

MEDICAL CARE

This will authorize release of information for all medical appointments including: Physician, Dentist, Eye Care Provider, Audiologist, Psychiatrist (med management), emergency medical attention, hospitalization and routine vaccinations

I authorize that the following information be exchanged:

____ Client status
____ Presenting problem and history of same
____ Diagnoses
____ Treatment plan(s)
____ Progress in treatment
____ Family involvement in treatment / ____ Psychiatric assessment(s)
____ Medication history and responses
____ Contact with & involvement with other agencies
____ Psychological assessments/evaluations
____ Substance abuse evaluation(s)
____ Discharge summaries

____ Other ______

The purpose for the exchange of information:

____ Coordination of treatment services
____ Communication between YAHA and support network
____ At request of client without additional purpose for exchange / ____ Case management
____ Interagency communication

____ Other ______

This consent may be revoked at any time unless a particular action depends upon the consent remaining in effect. However, any consent given under Subpart C, Federal Register. Volume 40-Number 127, July 1, 1995, which pertains to clients in alcohol and drug treatment, shall have duration no longer than that reasonably necessary to effectuate the purpose for which it is given.
Without expressed revocation this consent expires on:DATE: ______
Or specific event immediately after which this consent expires.
This consent will automatically expire 365 days from date of signature unless otherwise indicated.
Information obtained by this request cannot be distributed to other sources without your written consent.
Information released from your records at YAHA cannot be released by the party receiving that information without your written consent
An exact copy of this release shall be as valid at the original.
Treatment is not conditioned upon authorization for the request use or disclosure.

______(Client or Legal Guardian) Date

______

(Witness Signature)Date

YOUTH ALTERNATIVE HOME ASSOCIATION

CLIENT INFORMATION REQUEST OR RELEASE

Name of client: ______, DOB ______

I, the client, or the client’s parent/legal guardian, hereby authorize Youth Alternative Home Association (YAHA), P.O. Box 943, Evanston, Wyoming 82931, to obtain or release information for treatment or from my chart as specified below:

Information will be: ______released to______obtained from

High County Behavioral Health

(Name of person(s) or organizations)

PO Box 2910

(Street Address or Post Office Box)

EVANSTON, WYOMING 82931

(City, State, Zip Code)

__(P) 307-789-4224 (F) 307-789-4225__

(Phone and/or Fax)

I authorize that the following information be exchanged:

____ Client status
____ Presenting problem and history of same
____ Diagnoses
____ Treatment plan(s)
__ __ Progress in treatment
__ __ Family involvement in treatment / _____ Psychiatric assessment(s)
_____ Medication history and responses
_____ Contact with & involvement with other agencies
_____ Psychological assessments/evaluations
__ ___ Substance abuse evaluation(s)
__ ___ Discharge summaries

____ Other ______

The purpose for the exchange of information:

__ ___ Coordination of treatment services
_____ Communication between YAHA and support network
__ ___ At request of client without additional purpose for exchange / ____ Case management
____ Interagency communication

____ Other ______

This consent may be revoked at any time unless a particular action depends upon the consent remaining in effect. However, any consent given under Subpart C, Federal Register. Volume 40-Number 127, July 1, 1995, which pertains to clients in alcohol and drug treatment, shall have duration no longer than that reasonably necessary to effectuate the purpose for which it is given.
Without expressed revocation this consent expires on:DATE: ______
Or specific event immediately after which this consent expires.
This consent will automatically expire 365 days from date of signature unless otherwise indicated.
Information obtained by this request cannot be distributed to other sources without your written consent.
Information released from your records at YAHA cannot be released by the party receiving that information without your written consent
An exact copy of this release shall be as valid at the original.
Treatment is not conditioned upon authorization for the request use or disclosure.

______

(Client or Legal Guardian) Date

______

(Witness Signature) Date

YOUTH ALTERNATIVE HOME ASSOCIATION

CLIENT INFORMATION REQUEST OR RELEASE

Name of client: ______, DOB ______

Information will be: ______released to______obtained from

UINTA COUNTY SCHOOL DISTRICT #1

(Name of person(s) or organizations)

P.O. BOX 6002

(Street Address or Post Office Box)

EVANSTON, WY. 82931

(City, State, Zip Code)

P: 307-789-0757

(Phone and/or Fax)

I authorize that the following information be exchanged:

____ Other ______

The purpose for the exchange of information:

____ Coordination of treatment services
____ Communication between Pioneer and support network
____ At request of client without additional purpose for exchange / ____ Case management
____ Interagency communication

____ Other ______

This consent may be revoked at any time unless a particular action depends upon the consent remaining in effect. However, any consent given under Subpart C, Federal Register. Volume 40-Number 127, July 1, 1995, which pertains to clients in alcohol and drug treatment, shall have duration no longer than that reasonably necessary to effectuate the purpose for which it is given.
Without expressed revocation this consent expires on:DATE: ______
Or specific event immediately after which this consent expires.
This consent will automatically expire 365 days from date of signature unless otherwise indicated.
Information obtained by this request cannot be distributed to other sources without your written consent.
Information released from your records at YAHA cannot be released by the party receiving that information without your written consent
An exact copy of this release shall be as valid at the original.
Treatment is not conditioned upon authorization for the request use or disclosure.

______(Client or Legal Guardian) Date