Consent for Medical and Dental Care

For questions about services or bed availability please call 507.328.6699 Fax: 507.328.6697 E-mail: [email protected]After availability confirmation please complete this form and fax or email to:**Form must be received prior to intake. Thank you! Client InformationClient’s Full Name Nickname Gender Male Female Date of Birth Place of Birth Social Security No.Last Known or Permanent Address City State ZipHome Phone Current Placement or location Height WeightRace/Ethnicity Primary Language Spiritual or religious affiliationTribal Affiliation, if any Is client adopted? Age at first # finalized Is client a State Yes adoption? adoptions? Ward? Yes No No Health Care Provider (physician, nurse practitioner) Person Responsible for Payment:Medical Insurance Provider and Policy No. Primary: Secondary: Legal Status of Placement Judge’s Name Delinquency EJJ Date and Time of Court Hearing Court File No. Billable CountyDate of Arrival Estimated Time of Arrival: Hold Type: DetentionCourt order will be: Faxed (507.328.6697) Sent with TransportContact Information Parent/guardian (1) Parent/Guardian name Parent’s Date of Birth Client lives with this parent? Yes NoStreet Address City State ZipHome Phone Work Phone Cell Phone Olmsted County Juvenile Detention Center 2118 Campus Drive SE, Rochester, MN 55904 Phone: 507.328.6699 Fax: 507.328.6697 (2) Parent/Guardian name Parent’s Date of Birth Client lives with this parent? Yes NoStreet Address City State Zip Home Phone Work Phone Cell Phone Who has custody of the client?Any restrictions on either parent’s involvement? Yes No If yes, what? Will the parent(s)/guardian(s) be supportive of and/or involved with this placement? Yes No If no, why? Does parent/guardian need an interpreter? Yes No If yes, what language/dialect? Lead Worker Referring agency Worker’s name Phone Street address City State ZipE-mail Cell Fax Other Professionals Currently Working with this Client Agency Worker’s Name Phone Agency Worker’s Name Phone Agency Worker’s Name Phone Agency Worker’s Name Phone Current School School and/or District # School Contact for this Client: Phone Client’s current grade level? Does the client have an IEP? IEP for what disability? Yes NoClient Profile What are the presenting problems that lead to this referral?What is the history of or contributing factors to the client’s problems?What are some of the client’s assets, strengths, interests or abilities?Current/Most Recent Diagnosis Axis I: Axis II: Olmsted County Juvenile Detention Center 2118 Campus Drive SE, Rochester, MN 55904 Phone: 507.328.6699 Fax: 507.328.6697 Axis III: Axis IV: Axis V: Date of Assessment? Completed By: List client’s current medications. In order for us to provide timely medical care we ask that all medications are brought with.Any health concerns or physical limitations? Yes No If yes, explain: Any cognitive, developmental, or IQ concerns? Yes No If yes, explain: Any school related problems? Yes No If yes, explain: Currently suicidal? Any history of suicide or self-harm? Any hospitalizations for mental health? Yes No If yes, explain: Any chemical abuse? Any Treatment History? Yes No If yes, explain: Any history of abuse, neglect, or trauma? Yes No If yes, explain: Any safety concerns of client being vulnerable with his/her peers? Yes No If yes, explain: Any history of this client victimizing or hurting others? Yes No If yes, explain: Delinquency History (or attach an offense history report) Current to Prior Offenses Class/Degree Offense Date DispositionHistory of Services Delivered Outpatient Services Name of Agency Dates of Service ResultResidential Services Name of Agency Dates of Service ResultServices You Are Requesting What treatment goals do you have for your client?Olmsted County Juvenile Detention Center 2118 Campus Drive SE, Rochester, MN 55904 Phone: 507.328.6699 Fax: 507.328.6697 What additional services does your client need?What is the post-placement plan for your client?Would you like program staff to communicate with you: Bi-Weekly Weekly Preferred method of contact:Supporting Documentation to be Provided When Applicable Psychological or Diagnostic Assessments Individual Education Plan (IEP)Psychiatric Reports Program Discharge ReportsSocial/Family Assessments Substance Abuse Assessments (Rule 25)Court Reports CASSI or YLSI assessment Copy of Court Orders Other: Use this space for any additional information you wish to share.Olmsted County Juvenile Detention Center 2118 Campus Drive SE, Rochester, MN 55904 Phone: 507.328.6699 Fax: 507.328.6697 Consent for Medical and Dental CareWhile your child is at the OCJDC, he/she may need routine or emergency medical or dental treatment. Emergency treatment will be provided as needed. Your consent is required for non-emergency evaluation and treatment. Examples of non-emergencies include care for minor acute illnesses such as strep throat or minor injuries. Consent can be given in writing or verbally.I hereby give my consent for medical/dental evaluation and treatment, including medications as needed and recommended by a duly licensed physician, certified nurse practitioner, and/or dentist for my child , while he/she is in the custody of OCJDC.I understand that I will be notified of any major medical, dental, and/or surgical care that is required.In order to provide continuity of care, I also authorize that my child’s medical records may be obtained from and transferred to any facility or medical provider where health care had been provided and to which they are referred for treatment or to any other correctional facility to which he/she is transferred. These recordsIF READ IN PERSON by person signing:______Signature Relationship Date: ______Print name of person signing above: ______IF VERBAL CONSENT: Name and Relationship of person spoken to: ____________Staff Witness Signature #1 Staff Witness Signature #2 Date______Interpreter Signature (as applicable)Olmsted County Juvenile Detention Center 2118 Campus Drive SE, Rochester, MN 55904 Phone: 507.328.6699 Fax: 507.328.6697

Consent for Medical and Dental Care

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