Forms for Referral / Admissions
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:
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.