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.

Age of the patient

Name of the Patient *

First

Last

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 (For Guardian)
I’m an Existing Patient (For Guardian)
I’m a New patient (For Youth)
I’m an Existing Patient (For Youth)

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

Is your child willing to participate in the Teen Partial Program?

(Be present in the family sessions and group sessions)

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

Does anyone who lives at home use alcohol and/ 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 that lives at home use alcohol and/ or drugs?

Yes
No

Is there a family history of any psychiatric disorders/ mental illness? Has anyone in the family ever been hospitalized for psychiatric reasons?

Yes
No

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

When did you first notice your child's signs or symptoms? What is the frequency, intensity, duration and onset of their symptoms?

Are you aware of any triggers or any stimuli for the problem?

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

As a parent, how stressed do you feel about this situation, and what changes would you like to see?

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

As a family, what would you like to achieve from the Teen Partial Program?

Please Submit then choose an appointment to speak to the coordinator