Program Application For The River Source In Arizona

How Did You Hear About Us?:*

If Other, please explain:*

Please let us know how you found theriversource.org (friend or keywords)

Name of Person Filling Out This Form:*

Relationship to Patient:*

Email Address:*

Phone Number:*

Alternate Phone Number:

What state are you located in?:*

Patient Information

Male Patient's Legal Name:*

Male Patient's Phone Number:*

Age:*

Date of Birth:*

Responsible Party Information

Parent/Guardian Name:*

Relationship:*

Custody of Patient?:*

Yes
No

Home Number:*

Address:*

Street Address City State ZIP Code

Employer:*

Work Number:*

Other Parent or Guardian

Parent/Guardian Name:

Relationship:

Custody of Patient?:

Yes
No

Home Number:

Address:

Street Address City State ZIP Code

Employer:

Work Number:

Form of Payment:*

Address

Street Address City State ZIP Code

Is the patient a danger to their self or others?:*

Yes
No

If yes, please explain:*

Has the patient had any past suicide attempts?:*

Yes
No

If yes, when was his most recent attempt? What method was used?:*

In the last 12 months, has the patient had any thoughts of suicide, along with an intention and plan?:*

Yes
No

If yes, when was his last suicidal thought, along with an intention and plan?:*

Currently, does the patient have any thoughts of suicide along with an intention and plan?:*

Yes
No

If yes, please explain:*

Has the patient ever been hospitalized for a mental health condition?:*

Yes
No

If yes, please explain:*

Please list all medication and food allergies:*

Has the patient ever had a seizure?:*

Yes
No

If yes, when and what caused it?:*

Please list all current medications, dosage, and the reason they are prescribed:*

Is the patient currently taking antipsychotic or other psychiatric medication?:*

Yes
No

Does the patient currently have a 30 day supply of his antipsychotic or other psychiatric medication or does he have valid refills?:*

Yes
No

If the patient does not have a 30 day supply of his antipsychotic or other psychiatric medication he may be required to see a psychiatrist or his physician who can prescribe the patient his medication. The patient's cost for this service is $100-$300 depending on his psychiatric service need.

Is the patient taking the medications as prescribed?:*

Yes
No

Please list any immediate medical concerns:*

In the past six months, has the patient had any rashes, wounds, abscesses, respiratory diseases, or other infections?:*

Yes
No

If yes, please describe the situation and the treatment that the patient received:*

Has the patient attended any drug and alcohol treatment centers in the past?:*

Yes
No

If yes, when was the date of his previous treatment?:

Does the patient drink alcohol?:*

Yes
No

Please specify how often the patient drinks alcohol:*

How much does the patient drink?:*

1-2
3-4
5 or more

What type of alcohol?:*

Beer
Wine
Liquor

Has the patient abused prescription medications or used street drugs in the past 12 months?:*

Yes
No

If yes, please list all substances used as well as how frequently the patient uses them:*

Date the patient last used drugs or drank alcohol?:*

In the past 12 months, has the patient been arrested?:*

Yes
No

If yes, why?:*

Briefly describe the patient’s relationship with their immediate family:*

Is the patient currently enrolled in school?:*

Yes
No

If not, why?:*

Please specify the patient's last grade completed in school:*

Does the patient have a:*

Please describe the patient’s willingness to be helped:*

Anticipated date of admission to The River Source:*

Anticipated length of stay:*

The River Source reserves the right to disqualify applicants for specific medical reasons that require a higher level of care. These medical reasons include but are not limited to:

-active Tuberculosis
-suicidal ideation with a plan, means, and/or intent
-acute psychosis
-infectious disease

A person who moves to a higher level of care will again become eligible for River Source program once medical situation is successfully handled.

*

I have read and understood the above.

Youth Program Admission Application

Youth Admission Form

Patient Information

Responsible Party Information

Other Parent or Guardian