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Required Documents

or Items Needed Prior to Youth's Intake

Please review the following list to make sure that all necessary items have been sent to Bobby Benson Center's Intake Coordinator.  All of these documents are required and need to be sent in prior to youth's admissions. Failure to submit any of the following will result in a delay in the youth's admission and may even result in the youth being placed on a waiting list.  

Bobby Benson Center has three sources of funding which are:

  • The Child and Mental Health Division (CAMHD)

  • Judiciary

  • Private (Private Insurance such as HMSA or Kaiser funds the youths stay)

 

Please note that some required documents are for CAMHD youth only as indicated in the checklist below. 

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The Document/Items Checklist

Items to be faxed to (808) 293-7196 attention: Andrea Nakashima no later than 10 business days of  youth's referral acceptance:

  • Copy of youth's Birth Certificate

  • CAFAS-5 Scale (CAMHD youth only)

  • Coordinated Service Plan (CSP) (CAMHD youth only)

  • Copy of youth's medical/dental card(s)

  • Copy of youth's ID card (If available)

  • School IEP (if applicable)

  • Any pertinent legal documents 

  • Any other updates pertaining to the youth that may effect their treatment while at the Bobby Benson Center (i.e. changes to their physical/mental health or legal situation)

Green Leaves

The following items need to be received by Bobby Benson Center's Intake Coordinator preferably two (2) weeks but absolutely no later than one (1) week prior to youth's admissions date.  

  • Documentation completed by a Physician of the youth's Physical Exam.  The exam must have a full review of systems and be signed and dated by the Physician.  Date of the exam must be within one year of the date of youth's admission to Bobby Benson Center. If physical has expired prior to youth's date of admission to Bobby Benson Center they will need to see a physician to obtain a current physical exam. You may utilize Bobby Benson Center's Physical Form HERE

  • TB clearance dated within one (1) year of admissions date at Bobby Benson Center.  TB clearance must include induration results and be signed and dated by the medical professional administering and reading the test results.  TB tests that come back as positive must have clearance by the State of Hawaii's TB branch prior to being admitted to the center.  

  • Completed Prescriptions and Medication History Form (2 pages total).  You can access the form HERE. (Page one (1) is for the Legal Guardian to sign, Page (2) is for the prescribing physician, psychiatrist or other prescribing medical professional to sign.  If youth does not currently take prescription medication then please indicated on the form not currently taking any prescribed medications. 

  • Bobby Benson Center's Flu Shot Consent Form- Legal Guardian to sign.  While the Flu Shot is highly recommended it is not mandatory for youth's admittance into treatment. Access the Flu Shot Consent form HERE.  

  • Bobby Benson Center's Health Insurance Verification and Waiver Form (Both forms require Legal Guardian's signature).  Access the Insurance Verification & Waiver Form HERE

 

 

It is also recommended that all youth who have MedQuest (such as HMSA Quest and AlohaCare Quest) switch Primary Care Physicians to Castle Health Clinic of Laie.  This will help to ensure the youth is able to receive medical care without delays.  Unfortunately Bobby Benson Center cannot do this change, only the Legal Guardian can call their insurance provider and request that the Primary Care Physician be changed.  You will need the following information: Castle Health Clinic of Laie, Phone number: (808) 263- 5017, Address: 55-510 Kamehameha Hwy Suite 5, Laie, HI 96762 (if they ask for a Physician's name you can give them Dr. Marc B. Shlachter.  

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