Intake Forms

Please carefully review and complete the following forms prior to your child’s scheduled intake. You will need to bring the completed forms with you to the intake meeting.

There are additional documents, items and pieces of information that you must bring with you to the intake meeting. Please carefully review the Intake Checklist for a list of these very important items.

PLEASE CONTACT US IF YOU HAVE QUESTIONS OR ARE IN NEED OF ASSISTANCE.

BASIC INFORMATION

FORMS & AUTHORIZATIONS

Child & Family Intake Information

Information about the child, family and family care team.

Emergency Contact Information Sheet

Contact information to be used in the event of an emergency.

Phone Contact Sheet

Phone contact information specifying accepted and restricted contacts.

School Enrollment

School information includes information regarding school(s) your child attended in the last two years.

Authorization & Release to participate

Authorizes your child’s enrollment in the residential treatment program and participation in program activities

Informed Consent for Treatment

This form is to be completed in collaboration with agency personnel.  This consent allows us to provide treatment to your child.

Release(s) of Information

One release needs to be filled out for each individual incoming information source.  This includes doctors, dental, mental health, etc.

Notice of Privacy Practices

This describes how clinical information may be used and disclosed and how you can get access to this information.

Privacy practices & Acknowledgement

Acknowledges that you have received our “Notice of Privacy & Practices” and that you are willing to have us communicate information about your child’s case as described.

Release for use of non-secure modes of communication

This release pertains to communication using non-secure modes, including telephone and internet-based communication.

MEDICAL INFORMATION FORMS & RELEASES

MEDICAL HISTORY QUESTIONNAIRE

General medical history and information.

MEDICAL RELEASE

Allows us to arrange medical care; this includes medications, emergency communication and transportation.

MEDICAL CONSENT FOR PROGRAM ACTIVITIES

MEDICAL CONSENT FOR PROGRAM ACTIVITIES

NEW PATIENT INFORMATION

Lane County Behavioral Health & Community Health Centers of Lane County

SPRINGFIELD KIDS DENTIST

New patient information..

MEDICAL RESOURCES

For clients with private insurance.

BHS PHARMACY FORMS

BHS Pharmacy payment plan and privacy practices agreements..

STATEMENT OF IDENTITY

Identity affidavit.

PROGRAM & RIGHTS INFORMATION FOR FAMILY

RECEIPT OF RIGHTS ACKNOWLEDGEMENT

Statement that documents that you have received a copy of our client rights, privacy policies and description of our agency’s approach to treatment and behavior management practices. These documents include the following:

Philosophy Statement

Child Management & Discipline

Client Rights Packet

Notice of Privacy Practices

OHP Client Rights Letter

CHILDREN'S RIGHTS & RESPONSIBILITIES

Orientation handout to help children understand what they can expect in the program.

REFERRAL INFORMATION

Are you looking for information about making a referral?