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Index of intake forms

These forms are downloadable individually or as a complete packet in ZIP format. Click on the form name in the table below to download.

 

FormDescription
Resident Handbook This is a copy of the rules and expectations for residents and families.  All admitted residents and families should download this packet for their review.
Authorization for Emergency Treatment

This allows the facility to provide emergency medical treatment for residents.  Any emergency treatment other than routine treatment will require the consent of the parent/guardian.  In the case of an emergency the residents’ parents/guardians will be contacted as soon as possible and asked to provide verbal consent for emergency medical treatment.

Community Services Waiver

This gives the facility permission to have the resident participate in community services activities.  Residents are permitted to participate in community services on Phase 2 and with permission of the facility and the resident’s admitting court.  This form requires a witness signature.  The resident will sign upon admission to the facility.

Consent for Medical Treatment

This allows the facility to provide routine medical treatment for residents.  Any treatment other than routine treatment will require the consent of the parent/guardian.  Routine medical treatment includes general physical evaluations and general medical checkup, and evaluations for common illness, by a licensed medical provider, dentist visits, eye exam, psychiatrist appointment, evaluations and medication evaluations.  This form requires a witness signature.  The resident will sign upon admission to the facility.
Insurance Information

This information needs to be completed by any family that has a resident covered by private medical insurance.  Residents covered by Medicaid do not need this included in their intake packet.

Info Packet letter This is a welcome letter to court and families for new and potential residents.
Letter to Parents regarding medical bills

This is a letter that needs signed by any resident covered under private insurance.  Residents who are covered under Medicaid do not need this form included in their intake packet.

Medical Screening Pre Intake

This form needs completed by a medical professional for any resident who is confined (detention) prior to the resident admission to PMCF.  This form needs to be completed by a medical professional.  Please be as detailed as possible in regards to the youth’s past and present medical, mental health and dental treatment.  Please list all current medications.

Parent Contract

This form needs completed by the parents/guardians of the resident.  This explains the responsibilities of the parents/guardians during the youth time at the facility.  This form requires a witness signature.

Parent Questionnaire This detailed document needs to be filled out by the parents prior to the intake date and presented to staff upon intake.  The probation officer can assist the parents as needed.  This will allow the staff to obtain family background information and to obtain the parents perspective on the youth and family’s needs.
Photo Authorization

The facility takes pictures of youth during monthly activities, graduation and recreation.  These photos are not released to the public.  However, there may be instances in which a resident is photographed during community services. While a resident name will not be released, this form gives permission for use of the resident’s image.  This form requires a witness signature.

Probation Officer Checklist This is a list of documents that should be presented to the case manager or facility on or before the date of intake.
Release of Information

This is a general release of information that should be signed by the parent.  This document will be used by the facility to obtain prior medical, mental health, and school information to better serve the youth needs.  A release should be completed for each service provider with the service providers name and address included on each release.  The resident will sign these forms upon admission.

Reporting Responsibilities This form informs parents/guardians that they are responsible for contacting agencies that may be providing financial assistance to the resident, and informing those agencies that the resident is no longer in the parents/guardians custody while the resident is placed at the facility.  This form requires a witness signature.
Special Accommodations This document should be filled out by the parents indicating any special accommodations that their child may need while at the facility.  If the youth does not need any special accommodations, please indicate in each section.
Visitor Confidentiality While the youth is placed at the facility, the family will see other youth and other families during visits and family groups.  The facility asks that everything that is seen and/or heard at the facility is kept at the facility.