Forms for Referral

In order to refer a child to Orchard Place, the

Referral Application, the Bio/Psycho/Social Assessment and the Placement Agreement need to be completed by the parent or guardian.

The Authorization for Release of Professional Information form must be completed for current and previous treatment or services providers and for all insurance and/or Medicaid. The form allows us to obtain records for the child and to contact insurance companies regarding benefits. Please complete one for each professional or agency who has worked with the child including the county DHS office (i.e. “Polk County DHS”) or Juvenile Court Office (i.e. “Warren County Juvenile Court”). They are considered the Health Care Provider and Orchard Place is the recipient. You may also sign a release at the office of the other treatment provider. Records can be faxed or mailed to us, please visit our contact page for details.

Funding

Court-ordered children are funded by insurance and/or Medicaid. If a child is covered by one or more private insurance policies, Medicaid mandates that these benefits must be accessed first. Children under a court order are Medicaid-eligible once they are placed outside the family home (admission). Medicaid covers the costs not covered by private insurance. If a child receives income due to child support, SSI, Social Security, adoption subsidies or other assets, DHS requires this income be contributed towards the costs of care while the child is in placement.

Children placed voluntarily are funded by private insurance and/or by Medicaid. Children who do not have insurance benefits and are not eligible for Medicaid prior to admission are eligible for Medicaid the first of the month after admission. Parents are responsible for payment of services until Medicaid eligibility begins.

Department of Human Services Health Services Application (Medicaid Application)

 

How to Refer

Professionals referring to our PMIC program are asked to fax or mail the following information to our Admissions Office:

Admissions staff are available for consultation. Those who seek more information or wish to make a referral are invited to contact an Admissions Coordinator to learn more about the program and, if appropriate, initiate a referral. In order to refer a child to Orchard Place, the Referral Application, the Bio/Psycho/Social Assessment and the Placement Agreement need to be completed by the parent or guardian. Campus tours are available. Admissions Coordinators can be contacted by phone or e-mail:

Talli Smith
Admissions Coordinator
(515) 287-9712
.(JavaScript must be enabled to view this email address)

Amy Stauffacher
Admissions Coordinator
(515) 287-9628
.(JavaScript must be enabled to view this email address)

Lori Dawson-Weeks
Director of Admissions
(515) 287-9615
.(JavaScript must be enabled to view this email address)

The Authorization for Release of Professional Information form must be completed for current and previous treatment or services providers and for all insurance and/or Medicaid. The form allows us to obtain records for the child and to contact insurance companies regarding benefits. Please complete one for each professional or agency who has worked with the child including the county DHS office (i.e. “Polk County DHS”) or Juvenile Court Office (i.e. “Warren County Juvenile Court”). They are considered the Health Care Provider and Orchard Place is the recipient. You may also sign a release at the office of the other treatment provider. Records can be faxed or mailed to us, please visit our contact page for details.

As you consider placing your child in a PMIC program, we suggest you contemplate the following:
• What are the credentials of the staff members who will be working with my child?
• What kind of background checks are done on staff members?
• How do staff members handle consequences for misbehaviors and behavioral emergencies?
• What kind of training does the direct care staff have?
• How often will my child see his/her therapist and psychiatrist?
• How will I be kept informed of my child’s progress?
• If a medication or dosage change is recommended, will I be consulted?
• What happens if my child’s behaviors become worse?
• What happens after my child is discharged?

 

State of Iowa PMICs

There are several Psychiatric Medical Institutes for Children (PMICs) in Iowa that children can be referred to: