Initially Required:
- The Children and Family Services Association standard application
- Service Order for Residential Treatment II
- Person Centered Plan
- Written social history
- Written family history (if not included in social history)
- List of all previous placements
- Copy of court document giving custody (if applicable)
- Psychological evaluation (when requested)
- Medicaid card or proof of insurance
- Report card from last grading period
- Terms of probation and name & phone number for juvenile court counselor (if applicable)
- Mental health consent(s) for release of information
- List of current medications
Required At or Before Pre-Service Visit:
- Immunization records
- List of allergies
- Social Security card
- Birth certificate
- Discharge summaries from past placements, if available
- Physical examination, within last year including a TB test
- School transcripts and/or Individualized Education Plan
Documents Needing to be Completed and Signed Before Day of Admission:
(Sipe's will provide these except Area Program Authorization & Updated Service Plan.)
- Financial Agreement
- NC Medicaid Residential authorization form
- Mental Health Area Program's Authorization of Placement and Payment
- Clothing and Belongings Handout
- Standing Order for Over the Counter Medications (signed by physician)
- Medical Clearance for Use of Restrictive Intervention (signed by physician)
- Therapeutic Leave Days form
- Updated Service/Treatment Plan, including diagnosis, including Sipe's as residential treatment provider
Required on Day of Admission:
(Sipe's will provide these forms.)
- Permission for Treatment
- Equestrian Release of Liability
- Treatment Agreement
- Sipe's Consent for Release and Exchange of Information
- Schedule date for initial treatment plan
- Admission medication review
- Copies of current prescriptions
- Clothing & belongings inventory
- Approved contact list
- Resident handbook verification of receipt
- Informed consent for behavior management & restrictive interventions
- Family and guardian handbook verification of receipt
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