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STEPPING STONES PROGRAM Admissio

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					                                2950 Tennyson St. • Denver, CO • 80212 • (303)638-9378 • (303)303-433-0787 FAX


                              STEPPING STONES PROGRAM
                            24-Hour Admissions Line: 303-638-9378
Stepping Stones is a 24-hour shelter and residential treatment program for adolescent boys ages 11-18 that
cannot live at home due to family conflict, legal problems, runaway, or other crises. The program is a licensed
Therapeutic Residential Child Care Facility (TRCCF) offering case management, assessment, mental health
treatment, health care, spiritual growth, life skills, and recreation in a safe living environment. Services are
individualized to meet the needs of each child and family with the goal of establishing a plan for the future. The
program also offers overnight respite care to support families and prevent further crises. Referrals can be
made by the county Dept. of Human Services, Mental Health Centers, Private Paying Clients or other funding
sources.


     Admissions Process:
     1. Call the 24-Hour Admissions Line (303-638-9378). Tennyson staff will inform you of bed
        availability and conduct a brief screening process.

     2. If the youth is accepted, arrange for the youth to be transported to the program.

     3. Complete the attached referral forms and fax or deliver them to us or have a parent attend
         the intake at the unit and complete the forms.* OUR FAX is (303) 433-0787

     * We prefer for the parent/guardian to sign release forms. For emergency after-hours
        referrals, if a parent is unavailable, we will ask for a few essential forms to be signed and
        then follow up with the ongoing worker and parent on the next business day to complete
        the additional paperwork.


     DIRECTIONS:
     Stepping Stones is housed in the
     Devita Cottage on the Tennyson Center                                      Stepping
     campus at 2980 Tennyson St. in Denver.                                     Stones


     From I-25, exit Speer North and follow                                                    Admin
     to 29th Ave. Go West on 29th to                                                          & School
     Tennyson St.                                                              Driveway       Building

     From I-70, exit Sheridan South and
     Follow to 29th Ave. Go East on 29th                                           Warren                  Huston &
     to Tennyson St.                                                              & Tilsley                 Miller
                                                                                  Cottages                 Cottages




Share/Forms/Stepping Stones/Intake Forms/Emerg Ref Forms                                                              ca 11-06
Admission Date:                                                                           PROGRAM: (Circle One)
Staff Initials:                                                                           Stepping Stones Int. Respite Ext. Respite


                                        Tennyson Stepping Stones Program
                                            REFERRAL DATA SHEET
CHILD’S LEGAL NAME:                                                                                            D.O.B:
                                     Last                       First                               MI

Date of Referral:___________        Person Making Referral:                                                    Ph:
                                                               Name                                 Relation

SSN:________________________ Medicaid #:__________________________ Gender:  Male  Female Transgendered

Ethnicity:         Caucasian         African-American  Asian/Pacific Islands  Hispanic/Latino  Native American
                   Multi-racial:                                                Other:

Religion/Faith:  Catholic  Protestant  Judaism  Islam  Unknown  None  Other:


FUNDING SOURCE: *please specify the name of the funding agency
 DHS:                                                          Private Pay:
 BHO/MH:                                                       Other:

FAMILY INFORMATION: *please check boxes for parties to receive meeting notices and reports.
 Primary Caretaker(s):                                                          Relationship:

Address:__________________________________City:_____________________State:______Zip:____________________________

Home Phone: _________________________ Work Phone: _________________________ Cell Phone:

 Other (specify):                                                               Relationship:

Address:__________________________________City:_____________________State:______Zip:____________________________

Home Phone: _________________________ Work Phone: _________________________ Cell Phone:

 Other (specify):                                                               Relationship:

Address:__________________________________City:_____________________State:______Zip:____________________________

Home Phone: _________________________ Work Phone: _________________________ Cell Phone:
  Marital Status (of primary caretaker):         Married     Separated     Civil Union  Unmarried
  Family Type:  Nuclear  Single Parent  Extended/Kinship  Foster                    Adoptive      Blended/Step-parent

Siblings: (name, age, relation)
Most Recent Living Situation:
 Family as described in “Family Type”                Foster / Group Home
 Detention                                           Residential/Shelter:
 Homeless                                            Other:
 Hospital

Legal Status:      Dependent/Neglect         Voluntary     Delinquency        PRT      No DHS/Court Involvement
Name of County Involved:
Legal Custodian:                                               Visitor Restrictions:
Total Number of Previous Placements:
Kinship____ Shelter____ Foster Care____ Group Home ____ Residential/TRCCF____ Detention____ Hospitalization
CASE CONTACTS:               *please check boxes for parties to receive notices of meetings and reports
 Caseworker:                                                  Other: (specify role)

County/Agency:                                                      Agency:

Street:                                                             Street:

City:                            State:____ Zip:                    City:                                 State:____ Zip:

Phone:                             Fax:                             Phone:                                 Fax:

Names, titles, and phone numbers of any other important case contacts:




EDUCATIONAL SERVICES:
Last School Attended:
City:                             State:                                      Current Grade:
Home School District:
Special Education:  No  Yes - Primary Disability :
School District Contact:                                                           Phone:
Has the District been Notified of the Placement?  No  Yes
School Placement: Tennyson (6 -8 )  Secondary School (9 -12 )  GED/Vocational  Other:
                                   th     th                           th     th



IMMEDIATE NEEDS OF YOUTH & FAMILY:
Reason for Referral: (check at least one box)      Is the Youth at Risk for:
Respite care (24 hours or less)                   Self-Harm / Suicidal Gestures               Yes       No     Unsure
Placement due to family conflict / youth behavior Sexualized Behavior                          Yes       No     Unsure
Youth awaiting entry into another program         Assaultiveness                               Yes       No     Unsure
Court-ordered placement / legal issues            Runaway                                      Yes       No     Unsure
Runaway / Homelessness                            Substance Abuse                             Yes        No     Unsure
Other:____________________________________________
Immediate Medical/Health Needs:                                     Schedule w/ TCC psychiatrist?                     Y     N
Current DSM Diagnoses of Child (if applicable):
Current Medications & Dosages:
Date of last physical exam:     /       /     Name of Dr./Clinic:
Date of last dental exam:       /       /     Name of Dentist/Clinic:

Cultural / Religious Needs:

INITIAL DISPOSITONAL GOAL: * please check at least one
   Return to parent’s home                                Return to foster home
   Emancipate / Independent living program                Enter long-term treatment program
   Evaluating placement options / Unsure at this time
   Emergency after-hours referral – please contact ongoing worker the next business day to discuss plan
Anticipated Length of Stay:
Signature of Person Completing Form:                                           Print Name:

INTERNAL USE ONLY:
Therapist:                                                          Teacher:
Case Mgr:                                                           Supervisor:
                          2950 Tennyson St. • Denver, CO • 80212 • (303)638-9378 • (303)303-433-0787 FAX



                             MEDICAL AUTHORIZATION AND RELEASE
                                       Stepping Stones

Child’s Name:                                                                                   DOB:


1. EMERGENCY TREATMENT: I hereby authorize Tennyson Center for Children to take the above named child to a
   physician or hospital in the case of an accident, injury, or illness, which requires immediate medical attention. I further
   authorize staff to sign for medical treatment of the above-mentioned child and release pertinent medical information to
   those involved in providing the emergency treatment.

    I understand that the County Department of Human Services responsible for this child will ultimately be held
    accountable for any unresolved medical statements/care or they will be paid through the
                                                    Insurance Plan.

    Policy Number:

2. OVER THE COUNTER MEDICATIONS: Colorado Department of Human Services licensing
   regulations prohibit Tennyson Center for Children from providing or administering any over-
   the-counter medication to a child in the absence of an order from a physician. As a result,
   the agency cannot give a child non-prescription medications (including but not limited to aspirin,
   Tylenol, ibuprofen) or use antibiotic ointments or topical creams for first aid purposes without the
   approval of a physician.

    The child’s physician may be willing to furnish the Tennyson Center for Children with a “standing
    order” authorizing the administration of specified over-the-counter medications that would be
    consistent with the child’s medical condition and current use of prescription medications. It is the
    sole responsibility of the undersigned to obtain any such written standing order and to
    provide it to the agency. (The physician’s office may fax the order directly to the agency at
    303-433-0787.)
3. PRESCRIPTION MEDICATION: I give my permission for authorized Agency staff to administer to the above named
   child the previously prescribed medication,                                   , and/or to administer said medication as
   prescribed by the consulting psychiatrist in accordance with Agency policy. **Please note that children in the
   residential treatment program who are taking prescription medication are medically evaluated on a regular basis by
   the consulting psychiatrist.

This Medical Authorization and Release shall remain effective during any time the child is receiving
services from Tennyson Center for Children. This Release and Authorization may be revoked or modified
at any time by providing written notification to the Agency's Chief Program Officer.



Parent/Guardian                                    Date                              Relationship to Child


Client Signature                                   Date


Witness                                            Date
Share/Forms/Stepping Stones/Intake Forms/Emerg Ref Forms   ca 11-06
                                2950 Tennyson St. • Denver, CO • 80212 • (303)638-9378 • (303)303-433-0787 FAX




                            AUTHORIZATION TO PROVIDE TRANSPORTATION
                                         Stepping Stones


Child’s Name:                                                                                         DOB:


I authorize Tennyson Center for Children to transport                                                            to and from the
Residential Treatment or Day Services programs.

I further authorize                                 to be transported off-grounds during his/her participation
in the Residential or Day Services programs for program activities.

This Authorization to Provide Transportation shall remain effective during any time the child is receiving
services from Tennyson Center for Children. This Authorization may be revoked at any time by providing written
notice to the Agency's Chief Program Officer.




Parent/Guardian                                                   Date                              Relationship to Child



Client Signature                                                  Date




Share/Forms/Stepping Stones/Intake Forms/Emerg Ref Forms                                                                      ca 11-06

				
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