Get Hf0114x137 Bhrtcfamily.doc

Filling out the HF0114x137 Bhrtcfamily.doc online can seem daunting, but this guide will help you navigate the process seamlessly. This document is essential for requesting residential treatment center placement for a child and requires careful completion to ensure all necessary information is included.

Follow the steps to fill out the form correctly.

1. Click the ‘Get Form’ button to access the HF0114x137 Bhrtcfamily.doc and open it in your online editor.
2. Begin by entering the date of your request in the designated field at the top of the form.
3. Provide the patient's information, including their full name, date of birth, sponsor's name, and sponsor's social security number.
4. Complete the patient address section with the current address of the child.
5. Fill out the custodial guardian information, including their name, address, and both home and work telephone numbers.
6. Answer the reason for the request by detailing why you are seeking residential treatment services for the child and your main concerns about their behavior.
7. Outline the child’s current living situation, including the marital status of their parents and the number of siblings.
8. Describe any disruptions to the family environment caused by the child's behavior, if applicable.
9. Detail evidence of any concerning behaviors such as substance use, psychiatric symptoms, or risky activities.
10. List the family and social supports available to the child, such as friends or community organizations.
11. Provide any involvement of other agencies such as juvenile justice, school, or child protective services and relevant contact details.
12. Fill out the section regarding treatment within the last 12 months, including services received, providers, and approximate dates.
13. Indicate if the child has accessed any military treatment facilities for behavioral health services, providing specifics.
14. List current medications the child is taking, along with their doses.
15. Review the document for completeness and accuracy. Once you are satisfied with the information entered, save your changes.
16. Download, print, or share the completed form as necessary, and ensure that any supporting documentation is faxed as instructed.

Complete your application for residential treatment center placement online today.