Please Complete: Health and Behavior Form

Health and Behavior Form

Page 1

This Document Must be Completed by a Parent/Guardian if the Participant is Under the Age of 18

OVERVIEW

At VISIONS, it is our goal to provide an impactful and successful experience for each participant. To support that goal, and to benefit the wellbeing of the participant, it is imperative that all health and behavior information is fully disclosed. A participant will not be registered in a program until this form has been submitted and reviewed by a VISIONS representative. Please note the following:

  • In some cases, we cannot accept participants with conditions or situations that are incompatible with a program. We want everyone to have access to our programs, and we make all reasonable accommodations toward that end. Nonetheless, some situations require us to deny acceptance, including: 

  1. In-patient hospitalization or treatment in the last 12 months from program start date for:

  • Suicidal ideation/gestures/attempts

  • Eating disorders

  • Substance addiction

  • Violent behavior/legal issues

  • Active self-injurious behavior 

  • Other mental health hospitalizations

  1. Severe or unstable medical conditions such as seizures, diabetes, and cardiac disorders. 

  2. Ongoing concussion symptoms, repeated concussions, or traumatic brain injury within 6 months of program start date.


  • Living in a foreign environment may create unexpected physical and emotional stress, which may exacerbate otherwise mild conditions. Full disclosure will allow program leaders to be better prepared, and to facilitate a safe and successful experience.

  • We may require a signed mental health release form, and/or a signed physician release form, and/or a participant action plan for some health and behavior conditions. The VISIONS office will let you know if additional forms are required. 

  • Please contact the VISIONS office before the program start date if there are any changes or updates in health, behavior, or medications. 





example: 4'10"

example: 130






Allergies






Asthma/Respiratory Problems

VISIONS requires all participants with asthma or respiratory issues to bring with them the medications and associated devices (i.e.: inhaler, nebulizer, spacer, etc.) for all status levels, including: daily (green), caution (yellow), and emergency (red). We recommend bringing multiple emergency inhalers, depending on the severity of the case.



Food/Diet


Physical Restrictions




Mental Health
Prior to acceptance, participants with a history of psychotherapy must be medically stable. VISIONS is not appropriate for applicants who have just completed a residential treatment program.


Behavior
VISIONS is not a program for youth at risk, and inappropriate placement can be detrimental to the participant and to the program. Behavior issues are subject to reprimand and can lead to dismissal from the program without refund. 


Additional Information







Medication


Contacts and Insurance

First Emergency Contact
(OTHER THAN PRIMARY PARENT/GUARDIAN)
*PLEASE DO NOT INCLUDE MOTHER OR FATHER*




Second Emergency Contact
(OTHER THAN PRIMARY PARENT/GUARDIAN)
 *PLEASE DO NOT INCLUDE MOTHER OR FATHER*




Medical Providers
(This section is optional)













Health Insurance











* PLEASE NOTE THAT THE HEALTH AND BEHAVIOR FORM WILL NOT BE MARKED COMPLETE UNTIL THE OFFICE HAS REVIEWED AND ACCEPTED IT (THIS USUALLY TAKES A FEW DAYS). IF THERE IS SOMETHING ON THE FORM THAT THE OFFICE FEELS NEEDS FURTHER ATTENTION, WE WILL BE IN TOUCH. THANK YOU!