Complete this behavioral health history as detailed as possible. This document is used to complete a prior authorization with your insurance company. Your insurance will want to ensure that your daughter meets medical necessity for inpatient treatment. An incomplete, inaccurate or minor mental health clinical history will delay the admission process with your insurance company.
Note: It is possible to save this form and return to finish it at a later date. Simply scroll to the bottom and hit "save and continue later." After clicking the button, you will receive a custom link to your form and the option of receiving that link via email. Links to saved forms are valid for 30 days.
THINGS YOU WILL NEED ON HAND TO COMPLETE THIS FORM:
- Patient's and parents' SSN
- Insurance card
- Current list of medications
- Past list of medications
- List of places, dates of mental health treatments
- Medical and Psychiatric providers: Name, address, phone, fax information
IN ORDER TO BE CONSIDERED FOR TREATMENT
PAST CLINICAL RECORDS FROM MENTAL HEALTH TREATMENTS NEED TO BE SUBMITTED FOR CONSIDERATION BY OUR TREATMENT TEAM
PRIOR TO ADMISSION NEED TO SUBMIT
- Past mental health clinical records
- History and/or physical no older than 7 days before admission date
- Copy of front and back of insurance card
- Current immunization record
- Custody paper work
Patient and Family Information
Nickname, Preferred Name
Primary Insurance Information
MM slash DD slash YYYY
Secondary Insurance Information
MM slash DD slash YYYY
Legal Parent/Guardian #1
(first/middle/last)
Legal Parent/Guardian #2
Emergency Information
Who would you like us to contact if we cannot get a hold of parents
First Contact
Cannot be who child lives with
In the event of an emergency, I/We,
give permission to the staff at Trinity Teen Solutions & Heaven’s Peak Behavioral Health program, to contact this emergency contact, in the event that the staff is unable to reach me/us.
I/We
give authorization to staff at Trinity Teen Solutions & Heavens Peak Behavioral Health Services to call/email/text this designated emergency contact and release pertinent patient health information if they deem necessary in order to provide care and treatment to my daughter a minor patient.
MM slash DD slash YYYY
Second Contact
Cannot be who child lives with
In the event of an emergency, I/We,
give permission to the staff at Trinity Teen Solutions & Heaven’s Peak Behavioral Health program, to contact this emergency contact, in the event that the staff is unable to reach me/us.
I/We
give authorization to staff at Trinity Teen Solutions & Heavens Peak Behavioral Health Services to call/email/text this designated emergency contact and release pertinent patient health information if they deem necessary in order to provide care and treatment to my daughter a minor patient.
MM slash DD slash YYYY
I,
- am the
to the patient, attest that the information provided is complete and accurate. No information was omitted or exaggerated in an effort to obtain treatment for the patient. I/We agree that the information submitted by the Parent/Guardian represents and warrants to Trinity Teen Solutions and Heavens Peak Behavioral Health Services (hereinafter referred to as The Programs) that all the information submitted to The Programs in connection with the admission of the patient is true, accurate, complete, and states all information which should reasonably be known by The Programs to operate The Programs for the benefit of the patient and others. The accuracy and completeness of the information provided by the Parent is a material inducement to The Programs's admission of the patient in The Programs. Failure to provide accurate and complete information shall be a material breach of this Agreement, and The Programs shall have the right thereafter to terminate this Agreement.
MM slash DD slash YYYY
