Your Child Will Be Placed on Our PMIC Waiting List Once This Application Is Returned

Your child will be placed on our PMIC waiting list once this application is returned.

Referral Application

Date: ______

Child’s name: ______Date of Birth: ______

Child’s current placement: ______

If out of home placement, when was your child placed at this location? ______

Child’s legal guardian: ______

Child’s legal custodian: ______

Social Security #: ______County child is from: ______

Height: ______Weight: ______

Does your child have Title 19 (Medicaid)? ______Medicaid # ______

Is this a Medipass arrangement? ____ If so, please who is the Primary doctor:

Name ______, City ______, Phone# ______

Is your child covered by another insurance policy (such as Blue Cross or Hawk-i)? _____

Name of insurance company: ______Plan: ______

Policy holder’s name: ______DOB: ______

Employer: ______Policy #: ______

Employer phone number:______

Family Information

Mother: ______Phone #: ______

Address: ______

Father: ______Phone #: ______

Address: ______

If applicable:

Stepfather: ______Phone #: ______

Stepmother: ______Phone #: ______

Siblings, DOB: and current living arrangements:______
______Additional family information: ______

______

Service Worker Contacts

Does your child have a DHS worker? ______

DHS worker’s name: ______Phone #:______

Address: ______

Does your child have a Juvenile Court or Probation Officer? ______

Name: ______Phone #: ______

Address: ______

Is your child under a court order____ No, ______Yes, CINA_____ or Delinquent ______

Please list any individuals / organizations that work/worked with you, your family and your child regarding mental health concerns:

Out-patient therapy:

Name / Agency: ______Phone #: ______

Date started: ______Date ended: ______

Psychiatric or medication management:

Name / Agency: ______Phone #: ______

Date started: ______Date ended: ______

Hospital stay:

Name / Agency: ______Phone #: ______

Dates: ______

In-patient stays (PMIC, Residential Treatment, Mental Health Institute [MHI])

Name / Agency: ______Phone #: ______

Dates: ______

Behavioral Health Intervention Services (BHIS):

Name / Agency: ______Phone #: ______

Dates: ______

Other:

Name / Agency: ______Phone #: ______

Dates: ______

Comments regarding previous treatment (progress or willing to follow through): ______

______

______

Psychiatric and Medical Information

What is your child’s mental health diagnosis? ______

______

What are your child’s current medications and dosages? ______

______

______

______

Does your child have any medical conditions? ______

Please list: ______

______

Has your child been restrained or placed in a seclusion room? ______

School Information

School: ______Phone #: ______

Address: ______

Grade level: ______

Does your child have an IEP? Please circle LD, BD, MD, Level 1, Level 2, or Level 3

What does your child’s behavior look like while at school? ______

______

______

Reason for Referral and Goals

Why are you referring your child to Bremwood? (Include specific behaviors and add additional sheets of paper if necessary). Please include any past or current behaviors that include running away, self-harm, substance abuse, sexual acting out, or aggression.

______

______

______

Emotional triggers for your child:

__being touched __being isolated __bedroom door open

__people in uniform __particular times of the day __AM __mid-day __PM

__times of the year; when ______

__loud noises __ yelling

__any others: please describe______

Coping techniques your child uses:

__voluntary time alone __listening to music __reading a book

__sitting by an adult __watching TV/movies __talking to a peer

__walking around __writing a letter __talking to an adult

__playing a game __calling a therapist __punching a pillow

__doing hands on projects __writing in a journal __exercising

__deep breathing __going for a walk __taking a hot shower

__laying down __being outside __other ______

Trauma history

___ sexually abused: if yes, by whom and age, duration:______

___physically abused: if yes, by whom and age, duration:______

___sexually abuse someone else: duration, if yes, who?______

___physically abuse someone else? Duration, If yes, who?______

___witnessed physical or sexual abuse? What age, duration and explain:______

______

___experienced emotional abuse? By whom, duration and age:______

___ever experienced verbal abuse, ex. Name calling, etc.:______

___any other trauma such as, divorce death of a family member, car accident, neglect, rape, etc. ______

What type of involvement is your family willing to participate in during your child’s treatment?______

Family history of mental health issues:

Paternal side:______

______

Maternal side:______

______

Will your child go home after treatment? ______

If not, where will your child go? ______

What goals do you hope your child accomplishes while in treatment?______

______

______

What goals would your family like to accomplish while your child is receiving treatment?

______

______

______

Where did you learn about Bremwood?______

Additional Comments: ______

______

Please print name: ______

Signature: ______

Relationship to the child: ______

E-mail:______

Please return completed form to: Kristi Ewoldt

Bremwood Intake Specialist

PO Box 848 Waverly, IA. 50677

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