Admissions Process for Treatment

We’re Here to Guide You

Compassionate Care for At-Risk Youth

For more than a decade, Three Rivers Treatment Center has provided trusted residential services for teens ages 11 to 17. Our program is designed for adolescents navigating complex mental, emotional, or behavioral health challenges. This includes depression, substance abuse, defiance, anger, truancy, and diagnoses such as ADHD, ODD, and OCD.

We accept referrals from concerned parents, medical and mental health professionals, Social Services, school counselors, and the courts. At Three Rivers, we meet teens where they are, offering a safe, structured environment to help them heal, rebuild family connections, and rediscover their potential.

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Identifying Information of Youth

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Please enter a number greater than or equal to 0.

Guardian Information

Address

Placement Information

Youth’s Current Placement
Child’s address if different than the legal guardian
Concerning behavior checklist: If yes, please as when, where, and frequency of symptom or behavior
Fire Setting
Property Destruction
Depression
Self-Harm
Substance Use
Aggression
Running Away
Dropping Grades
Social Withdrawal
School Trouble
Change in Peer Group
Peer Conflict
Change in Sexual Patterns
Inappropriate Sexual Behavior

Prior Treatment Attempts

Type of Service: therapy, in-home, hospital, medication management
Date
Place
Outcome: some change, no change, etc.

Professional Evaluations Complete

Type of Exam

Psychological evaluation
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Psychiatric evaluation
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Neurological evaluation
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Forensic psychological eval
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Current Medications

Medication
Dosage
Frequency
Start Date

Medical Screening

Please indicate if this youth has any of the following medical concerns. If yes, please provide details.
Asthma
Diabetes
Seizures
Cardiac Issues
Allergies
Head injury
Visual Impairment
Hearing Impairment
Physical limitations
STI
Infectious Disease

Education

IEP
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504 Plan

Mental Health

Please list top 3 emotional & psychological needs for this youth from your perspective:

Preliminary Behavior Support Planning

Please list 3 behavioral/character strengths of this youth:
Please list 3 behavioral/character limits of this youth:
Please list top three triggers for unsafe behaviors:
Please list top three interventions that help in times of emotionally overwhelming situations or crises:
What techniques have you seen the youth use to help manage overwhelming emotions successfully:

Legal

Any past or current legal issues?
Currently on probation?

Community Contacts

Our partnership with community support systems is vital for the success of our youth and our program. Please list any and all community agencies (DSS, CSA, FAPT, CASA, Court Services Unit/Probation Officer, Victim Advocate, etc.) that are involved with this youth so that we may keep them informed.
Name
Phone
Fax
Agency
Alternative Phone
Emai
Signature
Clear Signature
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