EmailMeForm
Teen Residential Program Referral
Date of referral
*
MM
/
DD
/
YYYY
Date teen available for admission
*
MM
/
DD
/
YYYY
What is the best email address to contact you at?
Teen's Information
Please provide the following information for teen.
Teen's full name
*
First
Last
Teen's preferred name (if applicable)
Date of birth
*
MM
/
DD
/
YYYY
Sex
*
Male
Female
Gender Identity
*
Social security number
*
Parent/guardian name
*
Address of teen (if teen is placed outside of home, please indicate and explain in comment section)
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Comment section
Address of parent/guardian (if different from teen)
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Reason for referral and presenting problem
*
General statement about challenges the teen is experiencing with family, school, home or legal
*
Substances used/misused by teen
*
Alcohol
Benzodiazepines
Fentanyl
Marijuana
Meth
Mushrooms
Opioids
Over-the-Counter medications
Tobacco/Vape/Smokeless Tobacco/ Cigarettes
Diagnosis
*
Other
Other Substances Used/Misused
Past hospitalizations and recent treatment history.
Please include both inpatient, outpatient, community based and reason for referral to level of care.
#1
Place and date of service
Type of service
Reason for admission
Comments Regarding completion and/or effectiveness
#2
Place and date of service
Type of service
Reason for admission
Comments Regarding completion and/or effectiveness
#3
Place and date of service
Type of service
Reason for admission
Comments Regarding completion and/or effectiveness
#4
Place and date of service
Type of service
Reason for admission
Comments Regarding completion and/or effectiveness
#5
Place and date of service
Type of service
Reason for admission
Comments Regarding completion and/or effectiveness
Please list any medical conditions. allergies or current medication taken by the teen
*
A minimal 30-day supply of medications must be provided by the family at time of admission or the teen may not be admitted to the program.
Legal History
Teen is on probation
*
Yes
No
Name of court conselor(s)
Contact number for court counselor
###
-
###
-
####
Current pending charges
Court dates that will occur while teen is in treatment with Easterseals PORT Health
School History
Is teen currently enrolled in school?
*
Yes
No
IEP or 504
*
IEP or 504 plan currently
IEP or 504 plan in the past
No IEP or 504
School needs and goals
*
Referral Information
Contact information of referring agency.
Referring Agency/Person
*
Phone
*
###
-
###
-
####
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Email
*
Insurance Information
Copy of insurance card must be presented at time of screening, however you may attach a copy to the referral form as well.
Insurance Provider
*
Policy Number
*
Required Items/Documents for Admission
Please note that the following items are required for admission. Upload as many as you have.
Required Items/Documents for Admission
Any pertinent court documents
Birth Certificate
Documents to support past treatment history
Evidence of a 504 or IEP (if applicable)
Immunization Records
Insurance Card
Medical history for pre-existing medical conditions
Social Security Card
TB Skin Test and record of physical exam
Documents to Upload
Add File
Signature of Referring Person
*
Clear