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 and 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, ect.
• 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— This is to be filled out and signed by the child's physician prior to admission.
• McKenzie Pediatrics Patient Information— New patient information.
• Medical Resources— For clients with private insurance.
• BHS Pharmacy Form— BHS Pharmacy payment plan agreement.
• 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
  • LaneCare Client Rights Letter
    
    
• Children's Rights & Responsibilities— Orientation handout to help children understand what they can expect in the program.