Client Name(Required)

First Last

Client Date of Birth(Required)

Client Gender(Required)

Male

Female

What Insurance Does Client Currently Have?

Information of Person Completing Form

Your Name(Required)

First Last

Your Email Address(Required)

Your Phone Number(Required)

Your Relationship to Client(Required)

About This Form

Tanager Place is providing this form to potential inpatient clients to aid in and bring better understanding to our qualifications process.

In some instances, we are unable to provide inpatient services to a child. This could be due to special health or other considerations. Answers to some questions on this form may automatically disqualify a child from services. In those instances, information is provided on additional resources. Answers to other questions are potentially disqualifying, but more information is needed to make a full determination.

Disqualifying circumstances:

Inability to attend public school
Undergoing cancer or radiation treatment
Confinement to a wheel chair
Pregnancy
Diabetes
Impaired hearing

Your child deserves the best possible care. Please provide as much information as possible.

Can the client attend public school?(Required)

Yes

At this time, Tanager Place can only accept youth who can attend public school as part of our Inpatient Program.

You may want to browse available outpatient services.

Does the client have diabetes?(Required)

Yes

At this time Tanager Place cannot accept clients with diabetes into our Inpatient Program.

You may want to browse available outpatient or school based services.

Is the client currently pregnant?(Required)

Yes

At this time Tanager Place cannot accept clients who are pregnant into the Inpatient Program.

You may want to browse available outpatient or school based services.

Is the client currently a cancer patient or undergoing radiation treatment?(Required)

Yes

At this time Tanager Place cannot accept clients undergoing cancer treatment into the Inpatient Program.

You may want to browse available outpatient or school based services.

Is the client wheelchair bound?(Required)

Yes

At this time the Tanager Place Inpatient Program does not accept clients confined to a wheelchair.

You may want to browse available outpatient or school based services.

Is the client hard of hearing?(Required)

Yes

At this time clients who are hard of hearing are not eligible for the Tanager Place Inpatient Program.

You may want to browse available outpatient or school based services.

Is this a court-ordered or similar committal?(Required)

Yes

Child In Need of Assistance (CINA)?(Required)

Yes

JCO/Delinquent?(Required)

Yes

Does the client have a history of fire setting?(Required)

Yes

Please provide additional details about the client's history of fire setting in the space below:

Does the client have a history of sexualized behavior?(Required)

Yes

Please provide additional details about the client's history of sexualized behavior in the space below:

Does the client have a criminal history or criminal charges stemming from sexual offenses?(Required)

Yes

Please provide additional details about the client's history of criminal sexual offenses in the space below:

Does the client have any criminal history or criminal charges?(Required)

Yes

Please provide additional details about the client's criminal history or charges in the space below:

Does the client experience seizures or epilepsy?(Required)

Yes

Please provide additional details about the client's experience with seizures/epilepsy in the space below:

Does the client have congenital heart problems?(Required)

Yes

Please provide additional details about the client's congenital heart problems in the space below:

Prior Service & Treatment History

Psychiatric Hospitalization(Required)

Yes

Where?

When? (Month/Year)

Shelter Stays(Required)

Yes

Where?

When? (Month/Year)

Residential Treatment(Required)

Yes

Where?

When? (Month/Year)

Does the client see a psychiatrist?(Required)

Yes, currently

Yes, previously