Admission Application – Pure Faith House Inc

Application for Admission – Instruction Sheet

Thank you for your interest in Pure Faith House, Inc. and the program that we provide to youth throughout Virginia. To make a referral, please complete the Application for Admissions. The more thoroughly the application is completed the more helpful it will be in making an appropriate admissions decision.

Documents that are required prior to admission/placement for consideration of Admission are listed below. These documents may be faxed, mailed, or emailed to the facility.

Psychological Evaluation (within the past year) with a Full Scale IQ and all 5 DSM-V Axis’s
Social History (within the past year)
Current IEP (if applicable) and most recent school transcript
Educational evaluations and test scores
Previous Treatment/Counselling information
Copy of FAPT Treatment plan (if applicable)

Once these items have been reviewed and the appropriateness of the youth has been considered, an interview, as well as an admissions/pre-placement visit date, will likely be set. At the time of admissions/pre-placement visit, we will also need the following:

Assessment Information to Admission Application (PFH Form)
Placement Agreement (PFH Form)
Resident Emergency and Health Care Information (PFH Form)
Medical Treatment Authorization (PFH Form)
TB Screening (30 days before admission) (PFH Form)
Physical exam w/dental and vision exam date (within the past 90 days) (PFH Form preferred)
Standing Medication Orders to receive PRN medications (if applicable)
Medication Orders
Prescription Orders
Immunization Records
Copy of Birth Certificate
Copy of Security Card
Copy of Insurance Card
3-5 weeks supply of current medications
Certificate of Need (CON)
Child and Adolescent Needs and Strength Assessment (CANS)
Initial Plan of Care (IPOC)
Purchase of Service
Financial Agreement/Letter of Intent

Please use the above list as a checklist. If you have any questions please do not hesitate to contact the Admissions Coordinator at 757-232-2146. We look forward to working with you and again thank you for your interest in our program.

Application for Admission

Youth Details:

First Name

Middle Name

Last Name

Nickname

Date

Place of Birth:

Youth’s Social Security Number:

Race:

Select Sex:

Height:

Weight:

Eye Color:

Hair Color:

Marks, Scars, Tattoos:

Allergies:

Medication Allergies:

Other:

Last Known Address:

Religious Preference:

Legal Guardian: Relationship Details

Legal Guardian: Relationship:

Address:

Home Phone:

Work Phone:

Cell Phone:

Father Details:

First Name

Middle Name

Last Name

Address

Social Security Number:

Date of Birth:

Email:

Home Phone:

Work Phone:

Cell Phone:

Marital Status:

Stepmother’s Name:

Mother Details:

First Name

Middle Name

Last Name

Address

Social Security Number:

Date of Birth:

Email:

Home Phone:

Work Phone:

Cell Phone:

Marital Status:

Stepfather’s Name:

Sibling Details:

Please list brothers or sisters of youth. Identify step and/or half siblings and specify birth date.

Sibling 1

Name

Relationship

Birthdate

Address

Sibling 2

Name

Relationship

Birthdate

Address

Sibling 3

Name

Relationship

Birthdate

Address

Sibling 4

Name

Relationship

Birthdate

Address

Emergency Contact Information:

Contact Person:

Phone Number:

Address:

Agency Information:

Local Educational Agency:

Address:

Contact Person:

Phone Number:

Fax Number:

Cell Phone:

Youth’s Grade:

Is Youth Special Education:YesNo

Special Education Designation:

FSIQ:

Current School Status:AttendingTruant

Home School:ExpelledSuspended

Estimated Intellectual/Functional Capacity:Above AverageAverageBelow AverageDiagnosed MR

Educational Needs:

Base School:

Contact Person:

Phone Number:

Fax Number:

Email:

Social Services Agency Details (if applicable):

Social Services Agency (if applicable):

Address:

Contact Person:

Phone Number:

Supervisor:

Phone Number:

Fax Number:

Cell Phone:

Juvenile Court Services Agency Details (if applicable)/Other Details:

Juvenile Court Services Agency (if applicable)/Other:

Address:

Contact Person:

Phone Number:

Fax Number:

Cell Phone:

Please list legal charges, dates obtained, and disposition of charges:

Placement Reasons

Reason for Placement (description of problem behaviour in the past 30 days):

Please list last two placements and reasons why discharged:

Please identify feelings this youth struggles with managing effectively

Please identify stressors that provoke this youth:

Please identify interventions that work well in deescalating this youth:

Identifying Problems

(Please check all that apply)

Verbal aggression/disrespectIrritability/Mood SwingsImpulsivePhysical AggressionPsychological/PsychiatricAbandonment IssuesStealing/ShopliftingPoor/Low Academic PerformanceDifficulty w/Authoritative FiguresAbsconding/RunawaySelf-destructive BehaviorAntisocial BehaviorLyingLow MotivationSexually Inappropriate BehaviorSubstance AbusePeer RelationshipsSibling Related DifficultyFamily RelationshipsFire StarterSuicidal

Mental Health, Emotional, and Psychological Needs

(Identify Type and Frequency Needed)

Individual Therapy:

Family Therapy:

Other Therapies:

Describe Any Prior Therapy (Mental, Emotional, and Psychological)

Any Protection Needs to be Addressed [i.e. such as history of victimization, bullying, assaults, etc.]:

Describe Any Significant Risks to self and others [i.e. such as history of self-harm, substance abuse, AWOL, etc.]:

Describe Any Physical Health Needs to be noted [i.e. such as asthma, obesity, etc.]:

Describe Any Immunization Needs to be noted:

Describe The Suitability of the Resident Admission:

Please identify 3 short term objectives to be achieved during placement at PFH

1st:

2nd

3rd

Please identify 3 long term objectives to be achieved during placement at PFH

1st

2nd

3rd

Current Medications Details:

Current Medications 1:

Name

Dose

Schedule

Length of Time Taken

Current Medications 2:

Name

Dose

Schedule

Length of Time Taken

Current Medications 3:

Name

Dose

Schedule

Length of Time Taken

Current Medications 4:

Name

Dose

Schedule

Length of Time Taken

Recent Medication Changes: (if yes, explain)YesNo

Explain Modification Changes

DSM-IV Diagnosis

Axis I:

Axis II:

Axis III:

Axis IV:

Axis V:

Discharge Planning

Individuals who can assist in treatment and discharge planning (i.e. family, social worker, attorney, case worker, therapist, etc.)

Name

Phone Number

Relationship to Client

Services to be considered in planning discharge

Medication managementSubstance abuse servicesHousing assistanceCase managementIndividual counselingEducationMedical/dental/nutritional servicesFamily counselingLegal assistance/advocacyIndependent living skills/trainingTransportation/drivers educationVocational trainingOther

Insurance Information

Primary Insurance

Insurance Company:

Policy#:

Group#:

Insurance Company’s Telephone Number:

Employer’s Name

Employer’s Address:

Does this policy include:

Dental coverage?YesNo

PrescriptionYesNo

VisionYesNo

(You must provide a copy of insurance cards)

Secondary Insurance (if applicable)

Insurance Company:

Policy#:

Group#:

Insurance Company’s Telephone Number:

Employer’s Name:

Employer’s Address:

Does this policy include:

Dental coverage?YesNo

PrescriptionYesNo

Dental coverage?YesNo

VisionYesNo

(You must provide a copy of insurance cards)

I am confirming that have active health insurance. I understand that Pure Faith House must have a copy of this card immediately. I will also provide any updated insurance information if insurance coverage changes.

Printed Name

Date

Required Attachments

Assessment Information to Admission Application (PFH Form)
Placement Agreement (PFH Form)
Resident Emergency and Health Care Information (PFH Form)
Medical Treatment Authorization (PFH Form)
TB Screening (30 days prior to admission)
Physical exam w/dental and vision exam date (within the past 90 days)
Standing Medication Orders to receive PRN medications (if applicable)
Medication Orders
Prescription Orders
Immunization Records
Copy of Birth Certificate
Copy of Security Card
Copy of Insurance Card
3-5 weeks supply of current medications
Certificate of Need (CON)
Child and Adolescent Needs and Strength Assessment (CANS)
Initial Plan of Care (IPOC)
Purchase of Service
Financial Agreement/Letter of Intent

Upload All Documents

Person Submitting Application:

Printed Name

Date of Application

Work Phone:

FAX:

Offline Submission

Download the form for offline filling and submission with ease.

Download Form

Application for Admission – Instruction Sheet

Documents that are required prior to admission/placement for consideration of Admission are listed below. These documents may be faxed, mailed, or emailed to the facility.

Psychological Evaluation (within the past year) with a Full Scale IQ and all 5 DSM-V Axis’s
Social History (within the past year)
Current IEP (if applicable) and most recent school transcript
Educational evaluations and test scores
Previous Treatment/Counselling information
Copy of FAPT Treatment plan (if applicable)

Assessment Information to Admission Application (PFH Form)
Placement Agreement (PFH Form)
Resident Emergency and Health Care Information (PFH Form)
Medical Treatment Authorization (PFH Form)
TB Screening (30 days before admission) (PFH Form)
Physical exam w/dental and vision exam date (within the past 90 days) (PFH Form preferred)
Standing Medication Orders to receive PRN medications (if applicable)
Medication Orders
Prescription Orders
Immunization Records
Copy of Birth Certificate
Copy of Security Card
Copy of Insurance Card
3-5 weeks supply of current medications
Certificate of Need (CON)
Child and Adolescent Needs and Strength Assessment (CANS)
Initial Plan of Care (IPOC)
Purchase of Service
Financial Agreement/Letter of Intent

Application for Admission

Youth Details:

First Name

Middle Name

Last Name

Nickname

Date

Place of Birth:

Youth’s Social Security Number:

Race:

Select Sex:

Height:

Weight:

Eye Color:

Hair Color:

Marks, Scars, Tattoos:

Allergies:

Medication Allergies:

Other:

Last Known Address:

Religious Preference:

Legal Guardian: Relationship Details

Legal Guardian: Relationship:

Address:

Home Phone:

Work Phone:

Cell Phone:

Father Details:

First Name

Middle Name

Last Name

Address

Social Security Number:

Date of Birth:

Email:

Home Phone:

Work Phone:

Cell Phone:

Marital Status:

Stepmother’s Name:

Mother Details:

First Name

Middle Name

Last Name

Address

Social Security Number:

Date of Birth:

Email:

Home Phone:

Work Phone:

Cell Phone:

Marital Status:

Stepfather’s Name:

Sibling Details:

Please list brothers or sisters of youth. Identify step and/or half siblings and specify birth date.

Sibling 1

Name

Relationship

Birthdate

Address

Sibling 2

Name

Relationship

Birthdate

Address

Sibling 3

Name

Relationship

Birthdate

Address

Sibling 4

Name

Relationship

Birthdate

Address

Emergency Contact Information:

Contact Person:

Phone Number:

Address:

Agency Information:

Local Educational Agency:

Address:

Contact Person:

Phone Number:

Fax Number:

Cell Phone:

Youth’s Grade:

Is Youth Special Education:YesNo

Special Education Designation:

FSIQ:

Current School Status:AttendingTruant

Home School:ExpelledSuspended

Estimated Intellectual/Functional Capacity:Above AverageAverageBelow AverageDiagnosed MR

Educational Needs:

Base School:

Contact Person:

Phone Number:

Fax Number:

Email:

Social Services Agency Details (if applicable):

Social Services Agency (if applicable):

Address:

Contact Person:

Phone Number:

Supervisor:

Phone Number:

Fax Number:

Cell Phone:

Juvenile Court Services Agency Details (if applicable)/Other Details:

Juvenile Court Services Agency (if applicable)/Other:

Address:

Contact Person:

Phone Number:

Fax Number:

Cell Phone:

Please list legal charges, dates obtained, and disposition of charges:

Placement Reasons

Reason for Placement (description of problem behaviour in the past 30 days):

Please list last two placements and reasons why discharged:

Please identify feelings this youth struggles with managing effectively

Please identify stressors that provoke this youth:

Please identify interventions that work well in deescalating this youth:

Identifying Problems

(Please check all that apply)

Mental Health, Emotional, and Psychological Needs

(Identify Type and Frequency Needed)

Individual Therapy:

Family Therapy:

Other Therapies:

Describe Any Prior Therapy (Mental, Emotional, and Psychological)

Any Protection Needs to be Addressed [i.e. such as history of victimization, bullying, assaults, etc.]:

Describe Any Significant Risks to self and others [i.e. such as history of self-harm, substance abuse, AWOL, etc.]:

Describe Any Physical Health Needs to be noted [i.e. such as asthma, obesity, etc.]:

Describe Any Immunization Needs to be noted:

Describe The Suitability of the Resident Admission:

Please identify 3 short term objectives to be achieved during placement at PFH

1st:

2nd

3rd

Please identify 3 long term objectives to be achieved during placement at PFH

1st

2nd

3rd

Current Medications Details:

Current Medications 1:

Name

Dose

Schedule

Length of Time Taken

Current Medications 2:

Name

Dose

Schedule

Length of Time Taken

Current Medications 3:

Name

Dose

Schedule

Length of Time Taken

Current Medications 4:

Name

Dose

Schedule

Length of Time Taken

Recent Medication Changes: (if yes, explain)YesNo

Explain Modification Changes

DSM-IV Diagnosis

Axis I:

Axis II:

Axis III:

Axis IV:

Axis V:

Discharge Planning

Individuals who can assist in treatment and discharge planning (i.e. family, social worker, attorney, case worker, therapist, etc.)

Name

Phone Number

Relationship to Client

Services to be considered in planning discharge

Insurance Information

Primary Insurance

Insurance Company:

Policy#:

Group#:

Insurance Company’s Telephone Number:

Employer’s Name

Employer’s Address:

Does this policy include:

Dental coverage?YesNo

PrescriptionYesNo

VisionYesNo

(You must provide a copy of insurance cards)

Secondary Insurance (if applicable)

Insurance Company:

Policy#:

Group#:

Insurance Company’s Telephone Number:

Employer’s Name:

Employer’s Address:

Does this policy include:

Dental coverage?YesNo

PrescriptionYesNo

Dental coverage?YesNo

VisionYesNo

(You must provide a copy of insurance cards)

Printed Name

Date

Required Attachments

Assessment Information to Admission Application (PFH Form)
Placement Agreement (PFH Form)
Resident Emergency and Health Care Information (PFH Form)
Medical Treatment Authorization (PFH Form)
TB Screening (30 days prior to admission)
Physical exam w/dental and vision exam date (within the past 90 days)
Standing Medication Orders to receive PRN medications (if applicable)
Medication Orders
Prescription Orders
Immunization Records
Copy of Birth Certificate
Copy of Security Card
Copy of Insurance Card
3-5 weeks supply of current medications
Certificate of Need (CON)
Child and Adolescent Needs and Strength Assessment (CANS)
Initial Plan of Care (IPOC)
Purchase of Service
Financial Agreement/Letter of Intent

Upload All Documents

Person Submitting Application:

Printed Name

Date of Application

Work Phone:

FAX:

Offline Submission

Thank you for your interest in Pure Faith House, Inc. and the program.

Download Form

Youth Details:

Legal Guardian: Relationship Details

Father Details:

Mother Details:

Sibling Details:

Please list brothers or sisters of youth. Identify step and/or half siblings and specify birth date.

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Emergency Contact Information:

Agency Information:

Social Services Agency Details (if applicable):

Juvenile Court Services Agency Details (if applicable)/Other Details:

Placement Reasons

Identifying Problems

(Please check all that apply)

Mental Health, Emotional, and Psychological Needs

(Identify Type and Frequency Needed)

Please identify 3 short term objectives to be achieved during placement at PFH

Please identify 3 long term objectives to be achieved during placement at PFH

Current Medications Details:

Current Medications 1:

Current Medications 2:

Current Medications 3:

Current Medications 4:

DSM-IV Diagnosis

Discharge Planning

Individuals who can assist in treatment and discharge planning (i.e. family, social worker, attorney, case worker, therapist, etc.)

Services to be considered in planning discharge

Insurance Information

Primary Insurance

Does this policy include:

Secondary Insurance (if applicable)

Does this policy include:

Required Attachments

Person Submitting Application:

Youth Details:

Legal Guardian: Relationship Details

Father Details:

Mother Details:

Sibling Details:

Please list brothers or sisters of youth. Identify step and/or half siblings and specify birth date.

Sibling 1

Sibling 2

Sibling 3

Sibling 4

Emergency Contact Information:

Agency Information:

Social Services Agency Details (if applicable):

Juvenile Court Services Agency Details (if applicable)/Other Details:

Placement Reasons

Identifying Problems

(Please check all that apply)

Mental Health, Emotional, and Psychological Needs

(Identify Type and Frequency Needed)

Please identify 3 short term objectives to be achieved during placement at PFH

Please identify 3 long term objectives to be achieved during placement at PFH

Current Medications Details:

Current Medications 1:

Current Medications 2:

Current Medications 3:

Current Medications 4:

DSM-IV Diagnosis

Discharge Planning

Individuals who can assist in treatment and discharge planning (i.e. family, social worker, attorney, case worker, therapist, etc.)

Services to be considered in planning discharge

Insurance Information

Primary Insurance

Does this policy include:

Secondary Insurance (if applicable)

Does this policy include:

Required Attachments

Person Submitting Application:

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