Youth
FOCUS Residential Treatment Center
PRTF Application
1601 Huffine Mill Road
Greensboro, NC 27405
Telephone (336) 681-4134
Fax (800) 518-1348
PERSON/AGENCY MAKING REFERRAL
Name/Agency:
Phone:
Phone (Cell):
Fax:
Email:
Address:
Zip:
City:
State:
County:
CLIENT INFORMATION
Name (First, Middle, Last):
Race:
Sex: M
Hair:
Eyes:
F
DOB:
Age:
Height:
Social Security #:
Weight:
Medicaid #:
Other Insurance Information:
MCO:
Completed Care Review for PRTF : Y
Care Coordinator:
Phone #:
LEGAL GUARDIAN INFORMATION
Name:
Relationship:
Phone:
Phone (Cell):
Fax:
Email:
Address:
Zip:
City:
State:
County:
COURT COUNSELOR INFORMATION (if applicable)
Name:
Phone:
Phone (Cell):
Fax:
Email:
Address:
Zip:
City:
State:
County:
N
DIAGNOSES:
(Check all that apply):
None
Problems with access to healthcare
Educational problems
Problems related to interaction with legal system
Financial problems
Housing problems
Occupational problems
Problems with primary support
Problems related to the social environment
Other psychosocial and environmental problems
Other:
GAF:
REASON FOR REFERRAL:
PSYCHIATRIC HISTORY:
MEDICAL HISTORY:
Primary Care Physician:
Medical Problems (Describe):
Current Medications:
Dosage:
Frequency:
FAMILY/SOCIAL HISTORY:
LEGAL HISTORY (If applicable):
EDUCATION HISTORY:
Last 3 schools attended:
County:
Current Grade:
Current IEP:
Y
Special Classes (LD, BED):
N
If yes, please provide copy with application.
Suspensions/Expulsions:
School Difficulties:
PRIMARY AREAS OF CONCERN:
If your client is accepted into the RTC-PRTF program, we will need:
1.
Provider #3404504, 12 bed PRTF
2.
A signed Certificate of Need form.
3.
Client must be authorized through the MCO before s/he can be admitted.
4.
Copy of the Comprehensive Clinical Assessment recommending PRTF placement
5.
Copy of the client’s Person Centered Plan with PRTF goals included and crisis plan
6.
Physical within 30 days of PRTF admission
7.
Copy of Immunization Records
8.
Medicaid/Insurance Card
9.
Legal documentation of guardianship and/or legally responsible person.
10.
Social Security Card
11.
School Records including a copy of the IEP if applicable
The following list includes some of the items you will need to bring with you to the RTC. All
clothes and personal items should be marked with the resident’s name.
 2-3 casual in season outfits for when the resident reaches Level IV as
indicated in the program milieu
 Underwear sufficient for 5-7 days
 Comfortable socks and sneakers
 Plain pajamas, nightgowns, bathrobe, appropriate for mixed company
 2 plain sweaters (no hoods or pockets)
 1 jacket or coat for outside wear
 Personal hygiene items such as a toothbrush, toothpaste, shampoo, conditioner,
plastic comb, brush, hair dryer, lotion, feminine hygiene products
 Wind-up or battery operated alarm clock

Small portable radio with headphones

Stationary or wireless journal

No more than 5 to 10 dollars spending money
If you have any questions in regards to this application, you may contact Hannah Labas at 336-6814134 or Lamont Harmon and/or Diana Cooper at 336-375-8333.