The following is a list of items and documents that need to be submitted at least 10 BUSINESS DAYS prior to youth's admittance to treatment. 

 

Please submit all items/documents via fax:

Fax # (808) 293-7196

Attention: Andrea Nakashima

 

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.  

Required Items 

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 affect their treatment (i.e. changes to their physical/mental health or legal situation)

Required Documents 

Access the Medical and Intake Forms HERE>

  • PHYSICAL EXAM: 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. 

 

  • TB: 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.  

  • PRESCRIPTION & MEDICAL HISTORY FORM: Prescriptions and Medical History 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.

  • MEDICAL HEALTH AND DENTAL INSURANCE FORM: Please ensure to fill out both Medical and Dental Insurance information in its entirety as this will prevent delays in your youth   

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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