Application

Step 1 of 16

Client Information

Name

First

Last

Assigned Gender at Birth

Identified Gender

DOB

Age

Ethnicity

Race, religion, nationality, or sexual orientation. Please describe anything of note:

Primary Insurance Provider

Secondary Insurance Provider

SSN

Height

*In feet and inches

Weight

*In pounds

Primary Address of Applicant

Street Address

Address Line 2

City

ZIP / Postal Code

State / Province / Region

Country

Step 2 of 16

Parent/Guardian Information

Parent/Guardian 1 Relationship

Parent/Guardian 1 Name

First

Last

Parent/Guardian 1 Phone

Parent/Guardian 1 Email

Preferred Contact Method

Parent/Guardian 1 DOB

Parent/Guardian 1 SSN

Parent/Guardian 1 Legal Custody Arrangement

Parent/Guardian 1 Physical Custody Arrangement

Parent/Guardian 1 Occupation

Parent/Guardian 1 Physical Custody Arrangement

Step 3 of 16

Parent/Guardian 2 Information

Parent/Guardian 2 Relationship

Parent/Guardian 2 Name

First

Last

Is your address the same as the applicant?

Yes (leave unchecked if no)

Parent/Guardian 2 Phone

Parent/Guardian 2 Email

Preferred Contact Method

Parent/Guardian 2 DOB

Parent/Guardian 2 SSN

Parent/Guardian 2 Legal Custody Arrangement

Parent/Guardian 2 Physical Custody Arrangement

Parent/Guardian 2 Occupation

What is your relationship with your child?

Step 4 of 16

Step-Parent 1 Information

Step-Parent 1 Relationship

Step-Parent 1 Name

First

Last

Is your address the same as the applicant?

Yes (leave unchecked if no)

Step-Parent 1 Phone

Step-Parent 1 Email

Preferred Contact Method

Step-Parent 1 DOB

Step-Parent 1 Legal Custody Arrangement

Step-Parent 1 Physical Custody Arrangement

Step-Parent 1 Occupation

What is your relationship with your child?

Step 5 of 16

Step-Parent 2 Information

Step-Parent 2 Relationship

Step-Parent 2 Name

First

Last

Is your address the same as the applicant?

Yes (leave unchecked if no)

Step-Parent 2 Phone

Step-Parent 2 Email

Preferred Contact Method

Step-Parent 2 DOB

Step-Parent 2 SSN

Step-Parent 2 Legal Custody Arrangement

Step-Parent 2 Physical Custody Arrangement

Step-Parent 2 Occupation

What is your relationship with your child?

Step 6 of 16

Emergency Contact (other than Parent/Guardian)

Emergency Contact (other than Parent/Guardian) Name

First

Last

Emergency Contact Phone

Relationship to Applicant

Address

Street Address

Address Line 2City

State

ZIP Code

Step 7 of 16

Referral Information

How did you hear about Destinations for Teens?

Please give the name(s) of the referral source including phone, fax number and email:

Step 8 of 16

Family Information

Parents'/Guardians’ current relationship status

If divorced or separated, please provide the date:

How do you believe your relationship has affected your child?

Describe the custody/visitation arrangement (legal/physical/medical):

Is the applicant/child adopted?

Yes (leave unchecked if no)

Were there any complications during birth mother's pregnancy or delivery?

Yes (leave unchecked if no)

Step 9 of 16

Educational Information

What is the highest grade your child has completed?

Is the applicant/child currently enrolled in school?

Yes (leave unchecked if no)

Name of current school:

Name of Primary Contact at current school:

Is your child behind in credits?

Yes (leave unchecked if no)

Has your child ever been assessed for learning challenges or disabilities?

Yes (leave unchecked if no)

Has your child ever been assessed for an emotional disturbance?

Yes (leave unchecked if no)

Does your child have an Individualized Education Plan (IEP)?

Yes (leave unchecked if no)

Describe the custody/visitation arrangement (legal/physical/medical):

Date of next IEP meeting:

Suspensions/Expulsions/Truancies?

Yes (leave unchecked if no)

Step 10 of 16

Primary Concerns

What specific events lead to your decision to seek treatment?

Step 11 of 16

Treatment History

Please list all previous, relevant placements and/or interventions (including therapists, psychiatrists, hospitalizations, treatment centers, etc.):

Has your child been in treatment?

Yes (leave unchecked if no)

Treatment List (Start Date, End Date, Name of treating person/facility, and Contact information)

History of Hospitalization:

Yes (leave unchecked if no)

Hospital List (List Name of Hospital, Social Worker Name, Social Worker Contact, and start and release dates.)

Psychological Testing?

Yes (leave unchecked if no)

Step 12 of 16

Psychological History

Please describe any major events your child has struggled with (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.) Please include the date and the event that occurred:

Has your child been diagnosed with a mental health issue or mood disorder?

Yes (leave unchecked if no)

Anger/Violence: Describe the way(s) in which your child expresses anger (physical, self-directed, sexually, property destruction, emotionally, etc.):

Has your child had any physical confrontations in the home or with others?

Yes (leave unchecked if no)

Has your child ever intentionally hurt themselves?

Yes (leave unchecked if no)

If yes, please describe (include date/reason):

Running away: Has your child ever run away?

Yes (leave unchecked if no)

Suicidality: Has your child ever had thoughts of suicide?

Yes (leave unchecked if no)

Suicidality: Has your child ever made a suicide plan?

Yes (leave unchecked if no)

Suicidality: Has your child attempted suicide?

Yes (leave unchecked if no)

Sexual activity: Please describe any risky, aggressive or inappropriate sexual behaviors (promiscuity, unprotected sex, perpetrating, deviance, etc.):

Mood issues: Does your child exhibit signs of anxiety, depression, mood swings, etc.?

Yes (leave unchecked if no)

Obsessions/Compulsions: Does your child experience recurrent thoughts or repeated behaviors that they cannot control?

Yes (leave unchecked if no)

Lying, stealing, vandalism, dealing drugs, criminal activity?

Yes (leave unchecked if no)

Unusual Behaviors: bedwetting, hallucinations, rituals, tics, isolation, obsessions or other?

Yes (leave unchecked if no)

Current or past eating concerns (binging, purging, restricting, past eating disorder diagnoses, etc.)

Yes (leave unchecked if no)

Substance-related issues: Does your child have any alcohol, substance and/or dependency related issues?

Yes (leave unchecked if no)

Other addictive patterns (e.g.: computer games, T.V., phone, internet, sex, gambling):

Yes (leave unchecked if no)

Legal Problems:

Yes (leave unchecked if no)

Family history of mental illness and/or substance abuse (e.g.: depression, anxiety, etc.):

Yes (leave unchecked if no)

Step 13 of 16

Medical Information

Applicant Primary Physician Name

Applicant Primary Physician Phone

Applicant Primary Dentist Name

Applicant Primary Dentist Phone

Does your child wear braces/retainer?

Yes (leave unchecked if no)

Does your child wear prescription glasses/contacts?

Yes (leave unchecked if no)

Does your child require any specialized medical equipment/devices, i.e. oxygen tank, hearing aid, glucometer, c-pap machine, etc.:

Yes (leave unchecked if no)

Date of last physical:

Please list any surgeries, serious illness and/or hospitalizations. Please include date/event:

Please list any prescription(s) your child is currently taking and why (include dosage, prescribing physician/phone):

Are there any known side effects of the medication?

Yes (leave unchecked if no)

Please describe previous history of medication (include name of medication, dosage, reason, prescribing physician):

Is your child currently taking any vitamins or supplements?

Yes (leave unchecked if no)

Does your child have a previous diagnosis of Type I or Type II diabetes?

Yes (leave unchecked if no)

Does your child have a previous diagnosis of Impaired Glucose Tolerance?

Yes (leave unchecked if no)

Does your child have a previous diagnosis of any type of immunocompromised illness?

Yes (leave unchecked if no)

Has your child been vaccinated for C19?

Yes (leave unchecked if no)

Has your child tested positive for C19?

Yes (leave unchecked if no)

Step 14 of 16

Medical Information

Please describe in detail any checked Items:

Immunizations: Is your child up to date on the following immunizations?

Yes (leave unchecked if no)

Select applicable:

Tetanus/Diphtheria

Measles, Mumps, Rubella

Hepatitis B

Date of Last Tetanus/Diphtheria Shot:

Date of Last Measles, Mumps, Rubella Shot:

Date of Last Hepatitis B shot:

List all allergies (food, medication, grasses, etc.), how activated and what happens

Does your child carry an inhaler or epinephrine pen?

Yes (leave unchecked if no)

Has your child ever been hospitalized for allergies/asthma?

Yes (leave unchecked if no)

Family Medical History: Please list any pertinent medical history in your child’s family:

Step 15 of 16

Insurance Information

** Please note: Failure to provide correct primary and/or secondary insurance information may result in unexpected financial responsibility. **

Primary Insurance Company:

Benefits Phone:

Policy ID

Emergency Contact

Policyholder’s Name:

First

Last

DOB

Policyholder’s Phone

Address

Street Address

Address Line 2City

State / Province / Region

ZIP / Postal Code

Occupation

Social Security Number:

Step 16 of 16

Secondary Insurance Information

Secondary Insurance Company:

Benefits Phone:

Policy ID

Emergency Contact

Policyholder’s Name:

First

Last

DOB

Policyholder’s Phone

Address

Street Address

Address Line 2City

State / Province / Region

ZIP / Postal Code

Occupation

Social Security Number

Application

Our Programs & Activities Will Guide Your Teen Through Rehab

Client Information

Parent/Guardian Information

Parent/Guardian 2 Information

Step-Parent 1 Information

Step-Parent 2 Information

Emergency Contact (other than Parent/Guardian)

Referral Information

Family Information

Educational Information

Primary Concerns

Treatment History

Psychological History

Medical Information

Medical Information

Insurance Information

Secondary Insurance Information

We Are Here To Help.
Call Us Today!

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Application

Our Programs & Activities Will Guide Your Teen Through Rehab

Client Information

Parent/Guardian Information

Parent/Guardian 2 Information

Step-Parent 1 Information

Step-Parent 2 Information

Emergency Contact (other than Parent/Guardian)

Referral Information

Family Information

Educational Information

Primary Concerns

Treatment History

Psychological History

Medical Information

Medical Information

Insurance Information

Secondary Insurance Information

We Are Here To Help.Call Us Today!

Subscribe To Our Mailing List

We Are Here To Help.
Call Us Today!