**************** ROBERT J. KINSEY YOUTH CENTER ****************
****************** ADMISSIONS PACKET ********************

Child's First Name: Child's Last Name :
Age: DOB:
Address: Phone:
Race: Sex:
Height: Weight:
Hair: Eyes:
Place Of Birth: Social Security Number:
       
Family Background
Mother Name : Mother Address :
Mother Marital Status : Mother Employer :
Mother Work Hours :    
Mother Home Phone : Mother Work Phone :
Mother DOB : Mother Social Security Number :
Mother Allowed To Visit :    
       
Father Name : Father Address :
Father Marital Status : Father Employer :
Father Work Hours :    
Father Home Phone : Father Work Phone :
Father DOB : Father Social Security Number :
Father Allowed To Visit :    
       
Current Allegations    
Date: Time: Offense:
Date: Time: Offense:
Date: Time: Offense:
     
Previous Referrals      
Date: Charge: Detention: Disposition:
Date: Charge: Detention: Disposition:
Date: Charge: Detention: Disposition:
       
Health and Medical  
List prescribed medications  
Medication: Reason:
Medication: Reason:
Medication: Reason:
Has the child been exposed to any communicable diseases? Which ones?
Any other medical concerns, allergies etc.
   
Insurance  
Insurance Carrier:
Medicaid:
Insurance:
   
********** Admissions Agreement **********  
Date:

, a licensed child placement agency, does hereby request the Robert J. Kinsey Youth Center to receive for care .
I believe that this child poses a threat to self or others only as described below.
I further believe that this child is under the influence of drugs or non-prescription drugs only as described below.
I agree if the Robert J. Kinsey Youth Center accepts this child for care that:
1. Said child shall remain in the care of the Robert J. Kinsey Youth Center for the time designated by the court
2. Said child may be visited by approved visitors as stipulated below and under conditions stipulated by the Robert J. Kinsey Youth Center.
3. We, the undersigned, will be available for conferences regarding said child as requested by the Robert J. Kinsey Youth Center.
4. We, the undersigned, agree to provide written documentation of said child as requested by the Robert J. Kinsey Youth Center.
5. Any placing agency outside Howard County agrees to immediately remove any child whose removal is deemed appropriate
and/or necessary by the Robert J. Kinsey Youth Center.
6. We, the undersigned, agree to make monthly payments, as billed, at the per diem rate of $
   
PER DIEM:  
Shelter Care $162.00
Secure Detention $130.00
Shelter Care Diagnostics $310.00 or DCS contracted rate of $87.30 per billable hour
Secure Diagnostics $320.00 or DCS contracted rate of $87.30 per billable hour
PER DIEM IS BILLED FOR THE DAY OF ADMISSION IF PRIOR TO 10:00 PM AND RELEASE DAY IF AFTER 6:00 AM.
  
   
7. We, the Placing Agency agrees to assume responsibility for all medical, dental and psychiatric cost.
When insurance/Medicaid information is not provided by the Placing Agency.
   
I believe this child to be a threat to self or others: Yes No  
If yes, explanation:  
WE MUST REQUIRE THAT YOU PROVIDE A TELEPHONE NUMBER AND PERSON WHO CAN BE
CONTACTED ON A 24-HOUR BASIS.
Contact Person's Name: Contact Person's Title:
Telephone Number (Emergency/24 hour):  
Placement Agency Staff Signature: Date:
Kinsey Youth Center Staff Signature: Date:
   
********** Authorization Form **********
       
Name Of Child: Date:
Child's Signature:    
Parent/Legal Guardian Signature: Relationship To Child:
Staff Signature Witness: Date:
       
********** Consent for Medical Treatment **********
 
I, parent or legal guardian of the minor,
do hereby give permission for the personal for the Robert J. Kinsey Youth Center
to take said minor child to a doctor, therapist or hospital and authorize that person
to give consent for MEDICAL HEALTH treatment and sign an authorization on my behalf for
any MEDICAL HEALTH treatment or procedure deemed necessary by the attending physician.
I further accept all financial responsibility for costs incurred for treatment.
Parent or Guardian Signature: Date:
 
********** Consent for Mental Health Treatment **********
 
I, parent or legal guardian of the minor,
, do hereby give permission for the personal for the
Robert J. Kinsey Youth Center to take said minor child to a doctor, therapist or hospital and authorize
that person to give consent for MENTAL HEALTH treatment and sign an authorization on my behalf for
any MENTAL HEALTH treatment or procedure deemed necessary by the attending physician.
I further accept all financial responsibility for costs incurred for treatment.
Parent or Guardian Signature Date:
 
*********** ROBERT J. KINSEY YOUTH CENTER **********
*********** DETAINEE RELEASE AUTHORIZATION *******
*************** REQUEST FOR TRANSPORT *************
 
Detainee Name:  
Address:  
Date Of Birth:  
 
The above named juvenile is to be released from the Robert J. Kinsey Youth Center Pursuant to:
 
Court order for change in detention status:    
Charges have not been filed by the prosecutor in the prescribed time period.
The detainee is to be transported back to another jurisdiction for a hearing.
Date of Hearing: Time:
Court order that detention is no longer necessary and the detainee is to be released.
Transfer to Department of Corrections or other placement facility.
Time Served as Ordered:  
Release/Transport is to occur on Date:  
Authorized Signature: Date
 

***** Robert J. Kinsey staff will contact you the next business day to follow-up on******
*********** this admission and may request additional information ****************
In accordance with IC26-2-8(Uniform Electronic Transaction Act) I understand that by affixing my name as an electronic signature in the required areas I am entering into a contract with the Robert J. Kinsey Youth Center as outlined in the Admissions Agreement.