Forms for Referral / Admissions

Referral Forms:

Campus Access Form     CAMPUS FORMULARIO DE ACCESO

Health Screen     EXAMEN DE SALUD

Release of Information      AUTORIZACIÓN PARA LA DIVULGACIÓN DE INFORMACIÓN

Release of Information Substance Use    AUTORIZACION PARA REVELAR INFORMACION PROFESIONAL DE USO DE SUSTANCIAS

Insurance Information     INFORMACIÓN DE SEGUROS PARA EL LUGAR

Preadmission Financial Agreement     ACUERDO FINANCIERO DE PRE-ADMISIÓN

In order to refer a child to Orchard Place, the Campus Access Form, Provider  Release of Information, Health Screen, Insurance Information, Authorization for Release of Professional Information Forms,  and Preadmission Financial Agreement need to be completed by the parent or guardian.

The Authorization for Release of Professional Information forms must be completed for current and previous treatment or services provides as well as your child's school. The form allows us to obtain records for the child. 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 individual / agency. 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.

Forms for Admission:

Once a Child has been placed on our acceptance list:

Admissions Checklist  

Phone and Visit List 

Certificate of Need

Vaccine Administration Record

Certificate of Dental Screening

Funding for Services

DHS PMIC Information Sheet

Application for Health Coverage and Help Paying Costs 

The Orchard Place Campus Family Handbook helps parents understand more about policies and treatment programs we offer.  We also know it can be difficult for parents, as they rightfully have many questions about guidelines.  This document helps families understand the pre-admission process, family involvement, and your rights when it comes to utilizing Orchard Place Services.

The Orchard Place Resident Handbook describes what life is like on the Orchard Place Campus and includes guidelines so all residents are safe and secure while at Orchard Place.