Referral for Residency from the Applicant s Treatment Team

Similar documents
Midha Medical Clinic REGISTRATION FORM

PATIENT INFORMATION SHEET PHYSICIAN YOU ARE SEEING TODAY DATE OF OFFICE VISIT REFERRING PHYSICIAN LAST NAME FIRST NAME MI

Welcome to North Texas Orthopaedic & Spine 955 Garden Park Dr. Ste. 200 Allen Texas Today s Date: How did you hear of our practice?

X Guarantor/Parent/Guardian Signature

Horizon Eye Care, P.A. Patient Information Sheet. For your convenience, please print and complete the pre-registration forms before your visit.

PATIENT REGISTRATION FORM PATIENT INFORMATION

GREETINGS FROM THE VERDE VALLEY SCHOOL HEALTH CENTER

PATIENT REGISTRATION Must complete entirely. Reason for today's visit: New Patient: Y N Existing Patient: Y N. Date of Birth: Age:

Single Married Divorced Widowed Student Minor African American Asian Caucasian Hispanic Other:

Please bring the following with you to your appointment: Completed New Patient forms A list of all prescribed medications with dosages and quantity

THE AYURVEDIC CENTER OF VERMONT, LLC Health Information and History

Referring Physician: Type (Circle): Insurance Fitness Work/Comp Personal Injury Auto D/A:

Patient History Information

AGREEMENT AND INFORMATION

CARSON PHYSICAL THERAPY, INC.

Medical History Questionnaire

REHAB RESOURCES, INC. CONSENT FOR TREATMENT ASSIGNMENT OF BENEFITS BILLING AUTHORZATION ADULT (18 years and over)

Welcome to Tri-State Rehab Services

PERSONAL RECOVERY PROGRAM INTAKE APPLICATION

Welcome Letter - School Based Health Center

PATIENT INFORMATION - Please complete and/or verify all information and make changes as necessary.

Assisted Living Center - Salisbury

Advantage Physical Therapy Patient Registration

11120 New Hampshire Ave., Suite 411 Silver Spring MD Office (301) Fax (301)

ST. LAWRENCE REHABILITATION CENTER OUTPATIENT POLICIES AND REGISTRATION INFORMATION

1 Central 601 West Second Street, Bloomington, IN t

WELCOME TO AMOSKEAG CHIROPRACTIC, INC. SPINAL CORRECTIVE CARE FOR THE ENTIRE FAMILY ADULT. Full Name: What would you prefer to be called?

Patient Information. Last First MI (Preferred Name) Male Female Married Single Child. City State Zip Code Emergency Contact/Relation Phone

Florida Eye Center Patient Registration Form (Please Print Clearly)

Medicare Supplement Application Aetna Life Insurance Company Aetna Administrator, P.O. Box 10374, Des Moines, IA 50306

Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,, Body Region: Surgery Type: Date:,,

William A. Barber, MD, FACS Amanda. Morehouse, MD, FACS Erin Bowman, MD Anna Deriso, RNC, WHNP, MSN Kristy Donaldson, PA-C

PATIENT INFORMATION: PATIENT CONTACT PHONE NUMBERS: PHYSICIAN INFORMATION: HEALTH INSURANCE INFORMATION:

THANK YOU FOR CHOOSING QPT FOR YOUR PHYSICAL THERAPY NEEDS!

PREMIER PLASTIC SURGERY CENTER OF NEW JERSEY 310 MADISON AVENUE, SUITE 100, MORRISTOWN, NJ PHONE: FAX:

Patient Information Form Trinity Wellness Center. Insurance Information

Patient Case Information (Please Fill Out Forms Completely) (IF PATIENT IS UNDER 18 YEARS OF AGE LEGAL GUARDIAN MUST SIGN ALL PAPERWORK)

1455 West Fair, Marquette, MI Phone // Fax // info@mqtrehab.com

Beach Cities Medical Weight Loss

PATIENT REGISTRATION FORM PATIENT INFORMATION

Frequently Asked Questions About Our Preventative Care Offering

CENTENNIAL MEDICAL GROUP & CENTENNIAL SURGERY CENTER New Patient Paperwork

Stonebridge Adult Medicine, P.A. Registration Form (Please Print)

PLEASE BRING THE FOLLOWING WITH YOU TO YOUR APPOINTMENT:

Lake Oswego Eye Clinic 530 First ST, Suite A Lake Oswego, OR Office: (503) Fax: (503)

New Patient Registration Information

MEDICAL CLEARANCE FORM CHECKLIST

New River Health will bill private insurance, Medicaid, and CHIP for eligible students. No child will be denied services due to inability to pay.

Technical Assistance Document 5

STUDY ABROAD HEALTH CLEARANCE INSTRUCTIONS. For Students

Department of State Academic Exchanges Participant Medical History and Examination Form

Mangione Physical Therapy Please read and complete carefully by printing in ink. Provide all information requested.

Faculty Group Practice Patient Demographic Form

PELED PLASTIC SURGERY HEADACHE HISTORY FORM

3 Emergency Contact. Eaton Chiropractic & Rehab Center. 1 Patient Information. 2 Insurance / Guarantor. 4 Accident Information. Emergency Contact:

(928) MEDICAL HISTORY. Weight: _ Shoe size: _

Policy and Procedure Manual

New England Pain Management Consultants At New England Baptist Hospital

Electronic Health Records Intake Form

MILLRISE MEDICAL PRACTICE NEW PATIENT REGISTRATION/HEALTH QUESTIONNAIRE

Intake for Services. Birth date: Age: Gender: Name of Spouse: Years Married: Spouse's Age:

Pediatric Ophthalmology Date: PLEASE PRINT: PATIENT NAME: Male: Female: AGE: First Middle Last BIRTH DATE: / / HOME PHONE: (

PATIENT INFORMATION FORM

Welcome! We look forward to serving YOU. If we can do anything to make your time with us more enjoyable, please let us know.

Application Form. Global Green MBA

AON Physical Therapy & Wellness

New Patient Information Form

Patient Registration Form Please print clearly and complete all items. Patient First Name. Street Address. City State Zip

HSE Medical Associates Family Practice

Intake / Admissions Processes

Name: Location: Phone:

CONSENT FOR MEDICAL TREATMENT

MEDICAL POLICY No R1 MENTAL HEALTH RESIDENTIAL TREATMENT: ADULT

Patient Information: In Case of Emergency: Physician: Insurance:

INTEGRATED PHYSICAL THERAPY a whole- istic approach to physical therapy

Patient Information. Date: Date of Birth: / / Name: Social Security: _- - Address: Street City State Zip

Health Information Form for Adults

Medicare Patient Information. Patient Name: SS#: - - Date of Birth: / / Sex: Female Male. City: State: Zip Code:

1960 Ogden St. Suite 120, Denver, CO 80218,

[Provider or Facility Name]

Retinal Consultants of San Antonio Diseases and Surgery of the Retina and Vitreous com

PATIENT TREATMENT AGREEMENT

Cancellation/No Show Policy

San Ramon Valley Primary Care Medical Group Internal Medicine Patient Information Sheet

Notice of Privacy Practices Walter L Cohen High School School-based Health Center. Effective as of August 6, 2004

Consent Forms. The UltraWellness Center YOUR KEY TO LIFELONG HEALTH AND VITALITY

! 1220 Howell Street Ste. 110, Seattle, WA (206)

Here at PhysioDC we are committed to providing you with excellent care.

Ch HOSPICE SERVICES 55 CHAPTER HOSPICE SERVICES GENERAL PROVISIONS RECIPIENT ELIGIBILITY AND DURATION OF COVERAGE

HM Group Supplemental Hospital Indemnity Insurance Definitions

ADULT INTAKE QUESTIONNAIRE. Today s Date: Home phone: Ok to leave message? Yes No. Work phone: Ok to leave message? Yes No

Student & Health Information for Bates College Off-Campus Short Term Courses

INTEGRATED PHYSICAL THERAPY A Holistic Approach to Physical Therapy

RIDGE PHYSICAL THERAPY & WELLNESS CENTER. Intake Form

What is the Phoenix Transition Housing Program? What is the acceptance criteria? How do you apply to access the Phoenix Transition Housing Program?

Nearest Relative Information (Not in same household)

CAMARILLO AQUATICS AND REHABILITATION SERVICES

Section A Victim/Applicant Information (A separate application must be completed for each victim.)

OUTPATIENT SERVICES CONTRACT

Marian R. Zimmerman, Ph.D.

Transcription:

Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC 28756 828-894-7140 828-894-7111 FAX Referral for Residency from the Applicant s Treatment Team Applicant s Name Address City State Zip Male Female Marital Status Date of Birth / / Applicant s Parent(s), Guardian(s), or Spouse: (Please circle one) Address: Home Phone City State Zip Cell Phone If the applicant has a preference between CooperRiis two campuses, please indicate that below. Rural Mill Spring Urban - Asheville Is the applicant open to either campus? Yes No I. Strategic questions. Your considered and focused opinion about these issues is very important to us; please ATTACH your brief answers: (Any member of the Team may address these.) 1) What/Who prompts you to refer this applicant? 2) What do you perceive to be the key goals, hopes and dreams of the applicant? 3) What are the applicant s fundamental strengths that we can build on? 4) What are the crucial issues impeding the applicant s progress? 5) What are the main resources that CooperRiis can provide to assist with the applicant s recovery? II. Psychiatric Profile. Please attach all relevant records, psycho-social summaries and discharge summaries. Please also have the applicant sign and send authorization forms to relevant agencies/hospitals, asking that they send care summaries to us. (The applicant s physician must fill out this section.) A. Applicant s Diagnosis: B. Please submit a detailed, current psychiatric evaluation and prognosis, along with an overview of the applicant s psychiatric, social, educational and work history. C. What is your assessment about whether or not the applicant is currently at risk of suicide or inclined in any way to be destructive or abusive toward him or herself or others? Be specific as well about the history of such behavior. D. Is the applicant able to be responsible for his/her own behavior and safety in an open rural and/or urban environment, able to care for his/her personal hygiene, able and motivated to participate in the CooperRiis program, able to refrain completely from the use of alcohol and illegal drugs, able to confine cigarette smoking to designated areas, able to function relatively independently without close supervision? Yes No If the answer is no, please fully explain why in an attachment. Page 1 of 2

III. Current Medications: The applicant must arrive with at least a two week supply of all current medications. The medications will be dispensed based on this form. If there are ANY changes before the exploratory visit, please update us with a current medications list at the time of the visit. Medication Dose Time Taken Reason Prescribed Any PRN medications and for what target symptoms: Medication Dose Time Taken Reason Prescribed Previously unsuccessful medications? Is the applicant treatment adherent? If no, explain IV. Complementary Care for the Resident. CooperRiis program is comprehensive. In addition to providing psychiatric services, psycho-education, community work and service, and a therapeutic milieu, we incorporate nutritional and dietary planning, access to massage therapy and other modalities, smoking cessation and physical exercise programming into the resident s personal recovery plan. Which of these complementary approaches would be most beneficial for the applicant? (Please attach your answer.) V. Your suggested length of stay for the applicant? VI. Clinician Signature: (Attests to Section II and III) Printed Name Date Address: City/State/ZIP Phone Email Treatment Team Contact Person: Phone Email PLEASE SEND AT LEAST A TWO WEEK S SUPPLY OF ALL CURRENT MEDICATIONS 05/16 Page 2 of 2

Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC 28756 Family Form for Application to CooperRiis Applicant s Name Applicant s Social Security Number Date of Birth / / CooperRiis Pledge: We will do our best to provide your family member with a beneficial, comprehensive program of the highest quality, which should assist him or her in recovering from mental illness or emotional distress. Please help us to know of relevant background information: Your vision: Your family member will, of course, have his/her own vision or dream statement. We are also interested in your current hopes for him/her and for his/her future. Please write a brief statement that captures your desire and hope for your family member s recovery. What is your vision? What are some of the key things you hope CooperRiis will help your family member to achieve or accomplish? (You are welcome to use extra sheets.) Disclosure: The CooperRiis environment is open. There are no locked gates and we do not provide one-on-one supervision or staffing. Therefore, risky behavior can be difficult to monitor. Given this, we ask that you answer the following questions carefully, using a separate sheet of paper if necessary. 1) What is your assessment about whether or not the applicant is currently at risk of suicide or inclined in any way to be destructive or abusive toward himself/herself or others? Be specific as well about the history of such behavior. 2) What is your assessment of the applicant s ability.. a) to be responsible for his/her own behavior and safety in an open rural or urban environment? b) to care for his/her personal hygiene? c) to be able and motivated to participate in the CooperRiis program? d) to refrain from the use of alcohol and illegal drugs and to confine cigarette smoking to designated areas? e) to function relatively independently and safely without close supervision? By signing below I am indicating that I have provided the most accurate and truthful information regarding these crucial issues related to the safety and welfare of my loved one. Signature: Relationship to Applicant: Page 1 of 4

Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC 28756 Family Form for Application to CooperRiis..Continued We will offer our private, not-for-profit, professionally staffed program for a reasonable fee. CooperRiis has been built entirely from private philanthropy and continues to attract donations so that need-based rate reductions may also be offered after the first three months of residency to families who are unable to pay our standard fee. We ask that you read, answer and agree to statements a) through e). Please initial all that apply As parent(s), guardian, or spouse, of,, I (we) Applicant s Name a) Agree to pre- pay CooperRiis monthly program fee of $19,500 for the first month, plus a refundable security and incidental expense deposit of $1,000, upon admission, noting that the maximum monthly standard fee reduces to $15,500 as of the fourth month of residency. I (we) understand that fees are to be pre-paid on a monthly basis, from the day of arrival and that no refund allowances will be made for early discharges. Charges are also not reduced when a resident is away from the campus for trips home, for hospitalization, or vacations. In order to qualify for a rate reduction, the full rate of $19,500 must be paid for the first three months. Financial Assistance Explanation: After three months of residency, the standard rate reduces to $15,500 for all families. Parents, spouse or guardians, who are unable to sustain payments of the $15,500 standard monthly fee after the first three months of full rate, may seek a rate reduction. We will strive to meet the family s financial circumstances, especially for those residents who are demonstrating a strong commitment to their recovery. CooperRiis seeks to offer rate reductions based on the financial situation of the resident, of his or her parents (even if divorced), and/or of the resident s spouse or life partner (if there is one). If a reduced rate is set, pre-payments on a monthly basis will still be expected. Rate reductions will be limited to six month increments at each level of the program. As parent(s), guardian, spouse and/or life partner, of the applicant, I (we) [Please initial one]: b) Wish to notify CooperRiis that I (we) will seek a rate reduction at the appropriate time, or c) Do not expect that I (we) will seek a rate reduction, although I (we) do not waive my (our) right to re-consider this option later.

Page 2 of 4 Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC 28756 Family Form for Application to CooperRiis..Continued Additional mutual obligations: We are committed to communicating with you as much as the law allows about the applicant, during his or her residency. We will encourage the applicant to sign release of information forms that will authorize us to keep you fully informed about his or her condition. We hope that we will only be bringing you positive news. Nonetheless, despite our best efforts, this may not always be so. We may even approach you at an inopportune time and ask that you pick up the applicant immediately because of medical, psychiatric, legal, or behavioral reasons. Since we are a voluntary program, this need may also arise if the applicant decides to leave CooperRiis. You may also be asked to come, if the applicant has required local hospitalization and is not returning to CooperRiis. d) As the individual or individuals willing to take responsibility for the applicant, I (we) agree to come for him or her at once, if the Chief Program Officer or Managing Director asks us to do so. e) I(we) agree to participate in CooperRiis Family Education programs, which include at least one on-site, three day experience and participation in an online education program. This will be further explained and scheduled through your family member s recovery coordinator. f) I(we) also understand that the CooperRiis monthly fee does not include external physicians fees, medication, dental care, personal entertainment or transportation costs, phone calls, etc. Families often ask, What are the costs for any additional services that are not covered by the standard CooperRiis fee? The primary extra costs are: Psychiatrist: I (we) understand that fees for Psychiatric treatment will be billed to me (us) in addition to the monthly CooperRiis program fee, and I (we) will agree to pay these fees upon receipt of the billing. I am aware that I (we) are responsible to seek any insurance reimbursement for services rendered. (CooperRiis will provide a bill with coding that may help you obtain re-imbursement from your medical insurance company.) Cane Creek Pharmacy: I (we) understand that it is likely that my (our) family member will receive psychiatric medications and CooperRiis orders these medications on behalf of my (our) family member from Cane Creek. Also understand that the Pharmacy has the ability to bill the bulk of the costs for the medications to public and private insurance, if my family member has access to this coverage. Understand that I (we) are obligated to pay for any medication costs that are not covered by any existing insurance coverage. Dietary Supplements: I (we) understand that sometimes residents are advised to take supplements in addition to their regular medications by our Psychiatrists and our nutritionist. If so, I agree to these extra costs. Personal Transportation: I (we) understand that residents sometime require personalized transportation to airports, doctor s appointments, internships, etc. and that I will be obliged to pay for these extra services Drug Screens: I (we) understand that residents with drug use/abuse histories are required to submit to regular random drug screens as deemed appropriate by their CooperRiis Treatment team. If my family member is required, I(we) agree to these extra costs. g) I(we) also understand that CooperRiis does not file claims with private insurance companies or Medicare or Medicaid. The invoices that we provide may be used by the family to seek reimbursement from their private insurance company. We are not a Medicare/Medicaid provider. (If the applicant is a Medicare recipient, I acknowledge that a private provider contract is required for all psychiatric services provided) Page 3 of 4

Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC 28756 Family Form for Application to CooperRiis..Continued Disclosure: Movement between the CooperRiis programs will not occur until outstanding bills have been paid. I (we) pledge to comply with the requirements listed in a) g): First Signature: Date: Printed name: Relationship: Address: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email: Additional Signature: Date: Printed name: Relationship: Address: Home Phone: ( ) - Work Phone: ( ) - Cell Phone: ( ) - Email: Please give us a contact to reach in an emergency, if you can not be reached: Name: Home Phone: Business Phone: Cell Phone: Address: Medical Insurance Information: (Please attach copies of all insurance cards for Pharmacy.) *Note: CooperRiis does not file with Medicare/Medicaid or private insurance. Medicare: Medicaid: Other: 1/16 Page 4 of 4

Physical Form from Applicant s MEDICAL Treatment Team Applicant s Name Date of Birth / / Address City State Zip I. Medical Profile A. Applicant s Diagnosis (DSM-IV-R) Axis III: II. General Medical History: A. Please indicate whether the applicant currently has or has had any of the following medical problems. We require that all medical records/lab results relating to conditions for which the applicant is currently being treated and those that require ongoing treatment. B. Does the applicant use any medical aids/devices such as glasses, CPAP, hearing aids? C. Is this applicant capable of participating in a life skills program which includes physical work outside? If not, explain D. Any physical limitations/restrictions? E. Does applicant need further medical follow up? III. Current Medications Please send completed form to: CooperRiis, 101 Healing Farm Lane Mill Spring, NC 28756 Allergies and/or Adverse reactions to medications: Dizziness, fainting, seizures N Y Blood Pressure N Y Diabetes N Y Migraines N Y High Cholesterol N Y Cancer N Y Head Injury N Y Thyroid N Y Anemia/Other Blood disorder N Y Stroke N Y Neck/Back Injury N Y Kidney disease N Y Asthma/Lung Disease N Y Arthritis N Y Major surgeries N Y Heart Disease/Murmur N Y Fractures N Y Other N Y High Risk for TB N Y please provide proof of two-step TB test If yes, please explain: Medication Dose Time Taken Reason Prescribed IV. Physician Signature (Attests to Medical Profile): Printed Name Date Address: Phone City/State/ZIP Email 07/10

2024 © DocPlayer.net Privacy Policy | Terms of Service | Feedback  | Do Not Sell My Personal Information