ADOLESCENT ACUTE CARE CLINICAL PLACEMENT FORM

Please try and complete this form to the best of your knowledge to help facilitate placement.
If you have questions or trouble completing this form, please contact Alex Considine at 503-244-4257 or acutecareline@linesforlife.org

Client / Child Information

Gender Identity

Legal First Name

First Name Used

Last Name

Primary Contact

Primary Phone Number

Is it okay to leave messages

Comments (Extentions etc.)

County of Residence

Date of Birth

Age

Guardianship

Race/Ethnicity (Check all that apply)

American Indian or Alaska Native

Asian or Asian American

Black or African American

Hispanic or Latino

Native Hawaiian or other Pacific Islander

White or Caucasian

Unknown

Another race/ethnicity not listed

Insurance Information

Primary Insurance

Who is the client's CCO (coordinated care organization)?

Who is the client's care coordinator? (Name, Phone Number, Email)

Referring Agency And Clinical Information

Hospital Admission Date

Type of Referral

Referring Facility

Referring Clinician (First & Last Name)

Referring Clinician's Title/Position

Referring Clinician's Email

Referring Clinician's Phone Number

Primary Diagnosis

Secondary Diagnosis

Tertiary Diagnosis

Does client have any current substance abuse concerns?

Has client been diagnosed with a developmental disability?

Prefered Level of Care