Telehealth Teen Partial Program

Thank you for your interest in our partial teen program.
The purpose of this program is to help families, teens to find their purpose, have hope, make a goal, be functional to society, achieve mental remission, have safety and security in their lives.

In this program we will provide an overall understanding of family and teen focus dilemma. We will then Coordinate and mange to meet the patient and family mental health care goals. Parents and family members must participate in the program to find the best solution to their succeed in their recovery.

Please provider us with the following information to see if you are good candidate for this program.

Name of the Patient *

First

Last

Age of the patient

Name of the Parent *

First

Last

Name of the insurance company for the patient

Name of the insurance company for the parent

Please select from the following

I’m a New patient
I’m an Existing Patient

Are you willing to participate in the teen partial program?

Yes
No

Is the family willing to participate in the teen partial program?

Yes
No

In your opinion will your child be willing to participate in this program?

(Be present in the family sessions and group sessions)

What is the main reason you seeking mental health for your child?

Do you suspect that you child is abusing alcohol or any type of drugs?

Yes
No

can you please do an in-home test for your child to confirm or validate what kind of drugs are they taking?

Yes
No

Does anyone live at home use alcohol or drugs?

Yes
No

Is anyone in the family had past history of psych. Disorders or mental health disorders or psych hospitalization or have they taken any psych medication?

Yes
No

who is the person that have psych history, what is the medication, and what are the diagnosis?

Tell the reason of why you are seeking mental health for your teen and when did the problem started to occur?

Are you aware of any triggers or any stimulation to the problem?

Who do you think is very close to the teen ager in the family and is this person involved with the child now or not?

As a parent, how stressful do you feel about this situation and what is your treatment goal?

Who from the child’s family members will be participating in this program?

• What would you like to achieve as a goal from this teen partial program?

Please Submit then choose an appointment to speak to the coordinator