Residential Treatment Centers Troubled Boys

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Assessment Form - Mark Ward

Please complete this form with detailed answers. Your answers will be used to assist the therapist in developing an accurate treatment plan.

Your detailed answers will also be used in obtaining the best possible coverage from your insurance provider if such treatment is covered under your medical health insurance policy.

Failure to provide detailed answers will only hurt the development of an accurate treatment plan and delay or prevent the payment of your health insurance benefits (if any).

  • 1. FAMILY HISTORY

  • TREATMENT BARRIERS

  • 2. SELF HARM

  • 3. EDUCATION HISTORY

  • 4. SUICIDAL IDEATION

  • 5. VIOLENCE RISK ASSESSMENT

  • 6. EXPOSURE TO TRAUMA

  • 7. SEXUAL RISK ASSESSMENT

  • 8. SUBSTANCE USE HISTORY

  • Name of MedicationDosageFrequency TakenTime Period Medication Was TakenReason for Medication 
  • Name of MedicationDosageFrequency TakenWhen was Medication PrescribedReason for Medication 
  • 9. MEDICAL HISTORY OVERVIEW

  • Primary Physician NamePhone NumberSpecialty 
  • Psychiatrist NamePhone NumberSpecialty 
  • Prior Physician NamePhone NumberSpecialty 
  • 10. PSYCHIATRIC AND MENTAL HEALTH

  • Dates of TreatmentName of ProviderProvider AddressProvider Phone NumberReason for Treatment/Diagnosis 
  • 11. SOCIO-ECONOMIC

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  • About
    • F.A.Q.
    • Photo Gallery
    • Student Profile
    • Blog
  • Our Staff
  • Our Program
    • Therapeutic Programs for Troubled Boys
    • Residential Treatment Centers
    • Mental Health Treatment for Teen Boys
  • Family Support
  • Our Testimonials
  • Parent Education
    • All Boys Boarding Schools vs Residential Treatment Centers
    • Behavioral Modification Treatment Programs
    • Therapeutic Programs for Troubled Teens
  • Admissions
    • Contact Us
    • Apply for Financing
    • Verification of Benefits
    • Patient Financial Responsibility
    • HIPAA Privacy Practices
  • Parent Portal Program Daily Schedule