Case 2:85-cv-04544-DMG-AGR Document 515 Filed 11/02/18 Page 1 of 31 Page ID #:25677 EXHIBIT 3 REDACTED VERSION OF EXHIBIT FILED UNDER SEAL Case Document 515 Filed 11/02/18 Page 2 of 31 Page ID #:25678 Shiloh Treatment Center, Inc. Office of Refugee Resettlement Paquete de Admisi?n Acuerdo de Ubicacion Por medio de la presente solicito que _88 Ubicado en 6' Programa de Nombre del Cliente tratamiento subagudo Cl tratamiento residencial El tratamiento diurno (hospitalizaci?n parcial) en el Centro de Tratamiento Shiloh por aproximadamente 30 dias/ semanas/ l:l meses para el tratamiento de (enumere las razones de la ubicaci?n): suicidal ideation and La siguiente informaci?n encontrada en el Manual del Estudiante ha sido revisada a mi satisfacci?n: 1. Derechos individuales 4. Procedimientos de disciplina 2. Programacion servicios 5. Derechos del Cliente 3. Procedimientos de Visita 6. Responsabilidades Financieras Responsabilidad Financiera El otorgante es responsable de pagar todas las necesidades m?dicas, incluyendo pero sin restricci?n a honorarios m?dicos, medicinas, trabajos dentales, Ientes de aumento pruebas de Iaboratorio prescritas por un m?dico. Tratamiento Entiendo que esta instalaci?n coordinara un plan de tratamiento individualizado para el cliente. Evaluaci?n Entiendo que esta instalacion proveera una evaluaci?n, supervision seguimiento continuo por la duraci?n del cuidado necesario. Fotografias videos Entiendo que esta instalacion puede tomar fotos del cliente para el uso personal del cliente para propOSitos de identi?caci?n. Tambi?n entiendo que esta instalaci?n puede grabar videos del cliente en areas comunes de Ios hogares de ense?anza para monitorear las interacciones del personal el cliente. Solo para Tratamiento Subagudo Residencial Hogar Entiendo que en esta instalacion el personal estar? presente en el hogar a todo momento asumira la responsabilidad de su cuidado. Vestimenta Todos los articulos personales ropa ser?n provistos por la instalaci?n en la entrada del programa sera reemplazada cuando sea necesario. He leido entendido las politicas para la admision en el Centro de Tratamiento Shiloh Treatment Center. He acordado la admisi?n el 9/6/18 Fecha 9/6/18 3:42pm: Case manager contacted Ms. mother of minor _0 request Pam?tal consent. -statcd she was in agreement Wit minor being in placement and receiving medical treatment. Padres, Representante 0 Persona Responsable Fecha Fecha Ol-(p-lX Date Testlgo Rev. 03/14 Copy to Medical Chart and Travel Folder 01 Case Document 515 Filed 11/02/18 Page 3 of 31 Page ID #:25679 Shiloh Treatment Center, Inc. Office of Refugee Resettlement Admission Packet Affidavit Authorizing Consent to Medical Care Consent to Administer Prescription Medications Consent to Administer Non?prescription (OTC) Medications State of TEXAS BEFORE ME, the undersigned authority, on this day personally appeared who after being duly sworn by me, on his/her oath did say Parent, Guardian, or Conservator Name I am and I am the Mother Parent, Guardian, or Conservator Name Relationship to Client of who is in the care of Shiloh Treatment Center. Client Name If at any time such child or ward of mine should require medical or related care while in the care of Shiloh Treatment Center (Shiloh), consent to the administration of necessary medical or related care, including any appropriate medications, and authorize any approved representative of Shiloh to give consent to any doctor, emergency medical service, hospital, or other medical facility to provide medical or related care to such child or ward. I further give my permission for Shiloh to administer such medications that may be prescribed or recommended by medical personnel treating my child or ward. I understand that I will be noti?ed about medical care and the prescription of medication. Signature of Parent, Guardian, or Conservator 9/6/18 3:42 pm: Case manager contacted Ms. mother of minor to request parental consent._stated she was in agreement with minor being in placement and receiving medical treatment. SWORN TO AN SUBSCRIBED before me, the day of ,20 Signature of Notary Publlc Printed Name of Notary Public Notary Public for: County Rev. 09/10 File in Master Chart l-1 Case Document 515 Filed 11/02/18 Page 4 of 31 Page ID #:25680 Shiloh Treatment Center. Inc. Consent to Treatment with Medication The client. . has received a new medication The parent or guardian. . has received a complete explanation of Abilify (Aripiprazole) (Name of medication) The explanation was given to the parent or responsible party in a simple, nontechnical language and included: (Check all as accomplished.) The client?s diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s). including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment. if any. that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). El EiElEl The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). 0 Any side effects which are known to frequently occur in most individuals 0 Any side effects to which the individual may be predisposed The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroleptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. EilSlEl? An offer to answer any questions concerning the treatment. have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral explanation Printed material El Other: I have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medicationsts) for which I have given consent. Based upon this explanation. I hereby consent to treatment with the above medication(s). I understand that I may withdraw this consent at any time. Method of communication: Phone In person Fax El Mail Date treatment to be in: 9/1 ?18 9/24/18 Case Manager Date Relationship to client Physician. NP. PA. RN or LVN providing explanation Comments; Information on medication provided by case manager,? WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05/08 Shiloh Treatment Center, Inc. Office of Refugee Resettlement Paquete de Admisi?n Acuerdo de Ubicaci?n Por medio de la presente solicito que sea ubicado en el programa de Nombre del Cliente El tratamiento subagudo Eltratamiento residencial [j tratamiento diurno (hospitalizaci?n parcial) en el Centro de Tratamiento Shiloh por aproximadamente 30 B'dlas/ semanas/ meses para el tratamiento de (enumere Ias razones de la ubicaci?n): self-injurious behaviors, physical aggression, suicidal ideation, and mood instability. La siguiente informaci?n encontrada en el Manual del Estudiante ha sido revisada a mi satisfaccion: 1. Derechos individuales 4. Procedimientos de disciplina 2. Programaci?n servicios 5. Derechos del Cliente 3. Procedimientos de Visita 6. Responsabilidades Financieras Responsabilidad Financiera El otorgante es responsable de pagar todas las necesidades m?dicas, incluyendo pero sin restricci?n a honorarios m?dicos, medicinas, trabajos dentales, lentes de aumento pruebas de Iaboratorio prescritas por un m?dico. Tratamiento Entiendo que esta instalacion coordinar? un plan de tratamiento individualizado para el Cliente. Evaluacion Entiendo que esta instalaci?n proveera una evaluacion, supervisi?n seguimiento continuo por la duraci?n del cuidado necesario. Fotografias videos Entiendo que esta instalaci?n puede tomar fotos del Cliente para el uso personal del cliente para propositos de identificaci?n. Tambi?n entiendo que esta instalacion puede grabar videos del cliente en areas comunes de los hogares de ense?anza para monitorear Ias interacciones del personal el cliente. Solo para Tratamiento Subagudo Residencial Hogar Entiendo que en esta instalacion el personal estara presente en el hogar a todo momento asumira la responsabilidad de su cuidado. Vestimenta Todos los articulos personales ropa seran provistos por la instalaci?n en la entrada del programa sera reemplazada cuando sea necesario. He Ieldo entendido las pollticas para la admision en el Centro de Tratamiento Shiloh Treatment Center. He acordado Ia admisi?n el Fecha 9/06/18 2:15 pm Case Manager contacted the minor?s mother but there was no answer. 9/10/18 10:24 am Case Manager contacted the minor's mother and received received verbal consent for placement. Padres, Representante 0 Persona Responsable Fecha Cliente Fecha ?ho?y stigo Date Rev. 03/14 Copy to Medical Chart and Travel Folder C-1 Shiloh Treatment Center, inc. Office of Refugee Resettlement Admission Packet Affidavit Authorizing Consent to Medical Care Consent to Administer Prescription Medications Consent to Administer Non-prescription (OTC) Medications State of TEXAS BEFORE ME, the undersigned authority, on this day personally appeared who after being duly sworn by me, on his/her oath did say Parent, Guardian, or Conservator Name I am and I am the Mother Parent, Guar a or Conservator Name Relationship to Client of who is in the care of Shiloh Treatment Center. Client Name if at any time such child or ward of mine should require medical or related care while in the care of Shiloh Treatment Center (Shiloh), consent to the administration of necessary medical or related care, including any appropriate medications, and authorize any approved representative of Shiloh to give consent to any doctor, emergency medical service, hospital, or other medical facility to provide medical or related care to such child or ward. further give my permission for Shiloh to administer such medications that may be prescribed or recommended by medical personnel treating my child or ward. I understand that I will be noti?ed about medical care and the prescription of medication. Signature of Parent, Guardian, or Conservator 9/06/18 2:15 pm Case Manager contacted the mlnor?s mother, but there was no answer. 9/10/18 10:24 am Case Manager contacted the minor?s mother and received verbal consent for medical care. SWORN TO AN SUBSCRIBED before me, the day of ,20 SIgnature of Notary Public Printed Name of Notary Public Notary Public for: County Rev. 09/10 File in Travel Folder l-3 Case Document 515 Filed 11/02/18 Page 7 of 31 Page ID Shiloh Treatment Center, Inc. #25683 Consent to Treatment with Medication The client, . has received a new medication The parent or guardian, . has received a complete explanation of (ARIPIPRAZOLE) (Name of medication) The explanation was given to the parent or responsible party in a simple, language and Included: (Check all as accomplished.) The client?s diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s), including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). 0 Any side effects which are known to frequently occur in most individuals 0 Any side effects to which the individual may be predisposed - The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroleptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. El BEES An offer to answer any questions concerning the treatment. have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral explanation Printed material Other: have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medications(s) for which I have given consent. Based upon this explanation, I hereby consent to treatment with the above medication(s). I understand that I may withdraw this consent at any time. Method of communication: Phone '3 In person Fax Mail Date treatment to begin: 08/09/2018 09/28/2018 Case Manger Representative Signatu! Physician. NP. PA, RN or LVN providing explanation Comments; Information provided by Case Manager,? WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION I formally withdraw my consent to treatment with (Name of medication) Date Relationship to client Representative Signature Date Witness Date Revised 05/08 Case Document 515 Filed 11/02/18 Page 8 of 31 Page ID Shiloh Treatment Center, Inc. #25684 Consent to Treatment with Medication The client, has received a new medication The parent or guardian, 6-. has received a complete explanation of LEXAPRO (ESCITALOPRAM) (Name of medication) The explanation was given to the parent or responsible party in a simple, lanmge and included: (Check all as accomplished.) The client?s diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s), including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). Any side effects which are known to frequently occur in most individuals a Any side effects to which the individual may be predisposed The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroleptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. An offer to answer any questions concerning the treatment. BEE El SHEER I have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral explanation Printed material Other: have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medications(s) for which I have given consent. Based upon this explanation, I hereby consent to treatment with the above medication(s). I understand that I may withdraw this consent at any time. Method of communication: Phone In person Fax [3 Mail Date treatment to begin: 05? 5/2018 09/28/2018 Case Manger Representative Signa ure Date Relationship to client Physician, NP, PA, RN or LVN providing explanation Comments; Information provided by Case Manager- WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05/08 Case Document 515 Filed 11/02/18 Page 9 of 31 Page ID #:25685 Shiloh Treatment Center, Inc. Office of Refugee Resettlement Paquete de Admisic?m Acuerdo de Ubicaci?n Por medio de la presente solicito que sea ubicado en el programa de Nombre del Cliente El tratamiento subagudo tratamiento residencial tratamiento diurno (hospitalizacion parcial) en el Centro de Tratamiento Shiloh por aproximadamente at 2 dias/ [j semanas/ meses para el tratamiento de (enumere Ias razones de la ubicacion): suicidal ideations with a plan and self-injurious behaviors. La siguiente informacion encontrada en el Manual del Estudiante ha sido revisada a mi satisfacci?n: 1. Derechos individuales 4. Procedimientos de discipline 2. Programaci?n servicios 5. Derechos del Cliente 3. Procedimientos de Visita 6. Responsabilidades Financieras Responsabilidad Financiera El otorgante es responsable de pagar todas Ias necesidades m?dicas, incluyendo pero sin restricci?n a honorarios m?dicos, medicinas, trabajos dentales, Ientes de aumento pruebas de laboratorio prescritas por un m?dico. Tratamiento Entiendo que esta instalacion coordinar? un plan de tratamiento individualizado para el cliente. Evaluaci?n Entiendo que esta instalacion proveer? una evaluaci?n, supervisi?n seguimiento continuo por la duraci?n del cuidado necesario. Fotografias videos Entiendo que esta instalaci?n puede tomar fotos del cliente para el uso personal del cliente para propositos de identificaci?n. Tambi?n entiendo que esta instalacion puede grabar videos del cliente en areas comunes de los hogares de ensenanza para monitorear Ias interacciones del personal el cliente. Solo para Tratamiento Subagudo Residencial Hogar Entiendo que en esta instalacion el personal estara presente en el hogar a todo momento asumira Ia responsabilidad de su cuidado. Vestimenta Todos los articulos personales ropa seran provistos por la instalaci?n en la entrada del programa sera reemplazada cuando sea necesario. He leido entendido Ias politicas para la admisi?n en el Centro de Tratamiento Shiloh Treatment Center. He acordado la admision eI Fecha 9/06/18 3:36 pm Case Manager contacted the minor's mother, there was no answer. 9/07/18 10:40 am Case Manager contacted the minor's mother, and received verbal consent for placement. Padres, Representante 0 Persona Responsable Fecha Fecha Date Rev. 03/14 Copy to Medical Chan and Travel Folder C-1 Case Docume#nt 515 Filed 11/02/18 Page 10 of 31 Page ID :25686 Shiloh Treatment Center, Inc. Office of Refugee Resettlement Admission Packet Affidavit Authorizing Consent to Medical Care Consent to Administer Prescription Medications Consent to Administer Non?prescription (OTC) Medications State of TEXAS BEFORE ME, the undersigned authority, on this day personally appeared who after being duly sworn by me, on his/her oath did say Parent, Guardian, or Conservator Name I am and I am the mother Parent, Guardian, or Conservator Name Relationship to Client of who is in the care of Shiloh Treatment Center. Client Name If at any time such child or ward of mine should require medical or related care while in the care of Shiloh Treatment Center (Shiloh), I consent to the administration of necessary medical or related care, including any appropriate medications, and authorize any approved representative of Shiloh to give consent to any doctor, emergency medical service, hospital, or other medical facility to provide medical or related care to such child or ward. I further give my permission for Shiloh to administer such medications that may be prescribed or recommended by medical personnel treating my child or ward. I understand that I will be notified about medical care and the prescription of medication. Signature of Parent. Guardian, or Conservat 9/06/18 3:36 pm Case Manager contacted the minor?s mother, M-J-but there was no answer. 9/07/18 10:40 am Case Manager contacted the minor's mother, M.J-and received verbal consent for medical care. SWORN TO AN SUBSCRIBED before me, the day of ,20 Signature of Notary Public Printed Name of Notary Public Notary Public for: County Rev. 09/10 File in Master Chart I-1 Case Document 515 Filed 11/02/18 Page 11 of 31 Page ID #:25687 Shiloh Treatment Center, Inc. Consent to Treatment with Medication The client. has received a new medication The parent or guardian, M-J- has received a complete explanation of Cogentin (Benztropine) (Name of medication) The explanation was given to the parent or responsible party in a simple, nontechnical language and Included: (Check all as accomplished.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s). including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment, If any. that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). SUSIE 5 The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). Any side effects which are known to frequently occur in most individuals 0 Any side effects to which the individual may be predisposed The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuais taking neuroleptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. BEES An offer to answer any questions concerning the treatment. have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Orai explanation Printed material Other: I have received the Consent to Treatment with Medication form or information contained within that summarizes specific information regarding the medications(s) for which I have given consent. Based upon this explanation, I hereby consent to treatment with the above medication(s). I understand that I may withdraw this consent at any time. Method of communication: Phone In person Fax Mai: 07/ 10/201 8 Date treatment to be in: i0 Case Manager Representative Signature Date Relationship to client Physician, NP. PA, RN or LVN providing exptanation Comments; Information provided by Case Manager,? WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05/08 Case Document 515 Filed 11/02/18 Page 12 of 31 Page ID #:25688 Shiloh Treatment Center, Inc. Consent to Treatment with Medication The client, has received a new medication The parent or guardian, M.J- has received a complete explanation of Lexapro (Escitalopram) (Name of medication) The explanation was _given to the parent or responsible party in a simple, nontechnical language and included: (Check all as accomplished.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medlcation(s). The probable health and mentai health consequences of not taking medication(s), including occurrence, increase or recurrence of of mental illness. The existence of generally accepted aiternative forms of treatment, if any. that could reasonably be expected to achieve the same bene?ts as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s}. The risk of relevant side effects of varying degrees of severity associated with taking medications(s). 0 Any side effects which are known to frequently occur in most individuals 0 Any side effects to which the individual may be predisposed - The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroleptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. 51 [3833 An offer to answer any questions concerning the treatment. I have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral explanation Printed material [3 Other I have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medications(s) for which I have given consent. Based upon this explanation, I hereby consent to treatment with the above medication(s). I understand that I may withdraw this consent at any time. Method of communlcation: Phone in person Fax El Malt 08/08/201 8 {to i $12018 Case Manager Representativa Signa ure Date Relationship to client Physician, NP. PA. RN or LVN providing explanation Comments; Information provided by Case Manager,? WITHDRAWAL OF CONSENT TO TREATMENT MEDICATION I formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05/08 Case Document 515 Filed 11/02/18 Page 13 of 31 Page ID #:25689 Shiloh Treatment Center. Inc. Consent to Treatment with Medication The client. The parent or guardian, Zyprexa (Olanzapine) . has received a new medication . has received a complete explanation of (Name of medication) The explanation was given to the parent or responsible party in a simple, nontechnical language and Included: "(Check all as accomplished.) The client?s diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s). including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medicationsts). - Any side effects which are known to frequently occur in most individuals 0 Any side effects to which the individual may be predisposed The nature and possible occurrence of the potentially irreversible of tardive dyskinesla in some individuais taking neuroleptic medication in large dosages and/or iong periods of time. The need to advise staff immediately if any of these side effects occur. El An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. An offer to answer any questions concerning the treatment. have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral explanation Printed material Other; I have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medications(s) for which i have given consent. Based upon this explanation, hereby consent to treatment with the above medication(s). I understand that I may withdraw this consent at any time. In person El Fax Ci Mail Method of communication: Phone Data treatment to begin: 8/1 5/2018 to io{2018 Case Manager Representative Signature Date Relationship to client Physician. NP. PA. RN or LVN providing explanation Comments; Information provided by Case Manager, WITHDRAWAL 0F CONSENT TO TREATMENT WITH MEDICATION i formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05/08 Case Document 515 Filed 11/02/18 Page 14 of 31 Page ID #:25690 Shiloh Treatment Center, Inc. Office of Refugee Resettlement Paquete de Admision Acuerdo de Ubicaci?n Por medio de la presente solicito que sea Ubicado 9" 8' Programa de Nombre del Clients tratamiento subagudo tratamiento residencial tratamiento diurno (hospitalizacion parcial) en el Centro de Tratamiento Shiloh por aproximadamente 5Q dias/ semanas/ El meses para el tratamiento de (enumere Ias razones de la ubicacion): verbal and physical aggression, suicidal ideation with a plan, self?injurious behaviors, and making threats to hurt and kill others La siguiente informacion encontrada en el Manual del Estudiante ha sido revisada a mi satisfacci?n: 1. Derechos individuales 4. Procedimientos de discipline 2. Programaci?n servicios 5. Derechos del Cliente 3. Procedimientos de Visita 6. Responsabilidades Financieras Responsabilidad Financiera El otorgante es responsable de pagar todas Ias necesidades m?dicas, incluyendo pero sin restriccion a honorarios m?dicos, medicinas, trabajos dentales, lentes de aumento pruebas de laboratorio prescritas por un m?dico. Tratamiento Entiendo que esta instalacion coordinar? on plan de tratamiento individualizado para el cliente. Evaluacion Entiendo que esta instalaci?n proveera una evaluaci?n, supervision seguimiento continuo por la duracion del cuidado necesario. Fotografias videos Entiendo que esta instalacion puede tomar fotos del cliente para el uso personal del cliente para propositos de identificaci?n. Tambi?n entiendo que esta instalaci?n puede grabar videos del cliente en areas comunes de los hogares de ense?anza para monitorear Ias interacciones del personal el cliente. Solo para Tratamiento Subagudo Residencial Hogar Entiendo que en esta instalaci?n el personal estar? presente en el hogar a todo momento asumira Ia responsabilidad de su cuidado. Vestimenta Todos Ios articulos personales ropa seran provistos por la instalacion en la entrada del programa sera reemplazada cuando sea necesario. He leido entendido Ias politicas para la admisi?n en el Centro de Tratamiento Shiloh Treatment Center. He acordado Ia admisi?n el Fecha 9/06/18 3:37 pm Case Manager contacted minor's mother, and received verbal ennsenf for nlaeemenr Padres, Representante PersoniResponsable Fecha liente Fecha estigo Date Rev. 03/14 Copy to Medical Chart and Travel Folder C-1 Case Document 515 Filed 11/02/18 Page 15 of 31 Page ID #:25691 Shiloh Treatment Center, Inc. Office of Refugee Resettlement Admission Packet Affidavit Authorizing Consent to Medical Care Consent to Administer Prescription Medications Consent to Administer Non-prescription (OTC) Medications State of TEXAS BEFORE ME, the undersigned authority, on this day personally appeared who after being duly sworn by me, on his/her oath did say Parent, Guardian, or Conservator Name lam andlamthe mother Parent, Guardian, or Conservator Name Relationship to Client of 1? who is in the care of Shiloh Treatment Center. Client Name If at any time such child or ward of mine should require medical or related care while in the care of Shiloh Treatment Center (Shiloh), I consent to the administration of necessary medical or related care, including any appropriate medications, and authorize any approved representative of Shiloh to give consent to any doctor, emergency medical service, hospital, or other medical facility to provide medical or related care to such child or ward. I further give my permission for Shiloh to administer such medications that may be prescribed or recommended by medical personnel treating my child or ward. I understand that I will be noti?ed about medical care and the prescription of medication. Signature of Parent, Guardian, or Conservator 9/06/18 3:37 pm Case Manager contacted minor's mother, S- and received verbal consent for medical care. SWORN TO AN SUBSCRIBED before me, the day of ,20 Signature of Notary Public Printed Name of Notary Public Notary Public for: County Rev. 09/10 File in Master Chart l-1 Case Document 515 Filed 11/02/18 Page 16 of 31 Page ID #:25692 Shiloh Treatment Center, Inc. Consent to Treatment with Medication The client, . has received a new medication The parent or guardian, Wis- has received a complete explanation of ADDERALL XR (Name of medication) The explanation was given to the parent or responsible party in a simple, nontechnical language and included: (Check all as accomplished.) . The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s}, including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment. If any? that could reasonably be expected to achieve the same benefits as the medlcation(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medicationls). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). Any side effects which are known to frequently occur in most individuals - Any side effects to which the individual may be predisposed . The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroleptic medication In large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occuri An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. EBEESSES BEBE An offer to answer any questions concerning the treatment. I have received a complete explanation of the medlcation(s) by means of: (Check all appropriate methods) Oral explanation Printed material [3 Other: have received the Consent to Treatment with Medication form or information contained within that summarizes specific information regarding the medicationsfs) for which i have given consent. Based upon this explanation, I hereby consent to treatment with the above medlcation(s). I understand that I may withdraw this consent at any time. Method of communication: Phone In person El Fax El Ma? Date treatment be in: 08/15/2018 09124/2018 Case Manager Date Relationship to client Representative Signatur Physician. NP. PA. RN or LVN providing explanation Comments; Information provided by Case Manager, WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION formain withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Dale Revised 05/08 Case Document 515 Filed 11/02/18 Page 17 of 31 Page ID #:25693 Shiloh Treatment Center, Inc. Consent to Treatment with Medication The Client, has received a new medication The parent or guardian, . has received a complete explanation of (GUANFACINE ER) (Name of medication) The explanation was given to the parent or responsible party in a simple, nontechnicat language and included: ?geek all as accomj?shed.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected bene?cial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s). including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same bene?ts as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medicationsis). 0 Any side effects which are known to frequently occur in most individuals 0 Any side effects to which the individual may be predisposed The nature and possible occurrence of the potentially irreversible of tardive dyskinesla in some individuals taking neuroleptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. BIBS El ElEiEil BEIEIH An offer to answer any questions concerning the treatment. I have received a complete expian ation of the medication(s) by means of: (Check all appropriate methods) Oral explanation CI Printed material Other: I have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medications(s) for which i have given consent. Based upon this explanation. i hereby consent to treatment with the above medication(s). I understand that i may withdraw this consent at any time. in person Fax Mail Method of communication: Phone 09/04/2018 09/24/2018 Case Manager Representath Signat Date Relationship to client Physician. NP. PA. RN or LVN providing explanation Comments; information provided by Case Manager, WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05/08 Case Document 515 Filed 11/02/18 Page 18 of 31 Page ID #:25694 Shiloh Treatment Center, Inc. Consent to Treatment with Medication The client, has received a new medication The parent or guardian, has received a complete explanation of PROZAC (FLUOXETINE) (Name of medication) The explanation was given to the parent or responsible party in a simple, nontechnical language and included: _(?heck all as accomplished.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s). including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). 0 Any side effects which are known to frequently occur in most individuals - Any side effects to which the individual may be predisposed - The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroieptic medication in large dosages and/or tong periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. EIISEI ISISEIEI An offer to answer any questions concerning the treatment. have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral explanation Printed material Other: have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medications(s) for which i have given consent. Based upon this explanation. i hereby consent to treatment with the above medication(s). I understand that I may withdraw this consent at any time. Method of communication: Phone in person [3 Fax Mail Date ire - 09/05/2018 09/24/2018 Case Manager Representative Signatur Date Relationship to ciient Physician, NP, PA. RN or LVN providing explanation Commem; Information provided by Case Manage- WITHDRAWAL 0F CONSENT TO TREATMENT WITH MEDICATION formally withdraw my consent to treatment with (Name of medication} Representative Signature Date Witness Date Revised 05/08 .. Case Document 515 Filed 11/02/18 Page 19 of 31 Page ID #:25695 Shiloh Treatment Center. Inc. Office of Refugee Resettlement Paquete de Admisi?n Acuerdo de Ubicaci?n Por medio de Ia presente solicito que sea ubicado en 8' programa de Nombre del Clients tratamiento subagudo El tratamiento residencial tratamiento diurno (hospitalizaci?n parcial) en el Centro de Tratamiento Shiloh por aproximadamente 30 dlas/ semanas/ meses para el tratamiento de (enumere las razones de la ubicaci?n): suicidal ideation with a plan and self-injurious behaviors. La siguiente informaci?n encontrada en el Manual del Estudiante ha sido revisada a mi satisfacci?n: 1. Derechos individuales 4. Procedimientos de discipline 2. Programaci?n servicios 5. Derechos del Cliente 3. Procedimientos de Visita 6. Responsabilidades Financieras Responsabilidad Financiera El otorgante es responsable de pagar todas las necesidades m?dicas, incluyendo pero sin restriccion a honorarios m?dicos, medicinas, trabajos dentales, lentes de aumento pruebas de laboratorio prescritas por un m?dico. Tratamiento Entiendo que esta instalacion coordinar? un plan de tratamiento individualizado para el cliente. Evaluaci?n Entiendo que esta instalaci?n proveera una evaluaci?n, supervisi?n seguimiento continuo por la duracion del cuidado necesario. Fotografias videos Entiendo que esta instalacion puede tomar fotos del cliente para el uso personal del cliente para prop?sitos de identificacion. Tambi?n entiendo que esta instalacion puede grabar videos del cliente en areas comunes de los hogares de ense?anza para monitorear las interacciones del personal el cliente. Solo para Tratamiento Subagudo Residencial Hogar Entiendo que en esta instalaci?n el personal estara presente en el hogar a todo momento asumira Ia responsabilidad de su cuidado. Vestimenta Todos los articulos personales ropa ser?n provistos por la instalaci?n en la entrada del programa sera reemplazada cuando sea necesario. He leido entendido las politicas para la admisi?n en el Centro de Tratamiento Shiloh Treatment Center. He acordado la admisi?n el Fecha 9/06/18 3:30 pm Case Manager contacted minor's mother, land reneived verbal (?ongent? for nlaoemenf Padres, Representante 0 Persona Responsa?ble Fecha if.? 6?4 61?21 i ?tjtigo Date Rev. 03/14 Copy to Medical Chan? and Travel Folder C-1 Case Document 515 Filed 11/02/18 Page 20 of 31 Page ID #:25696 Shiloh Treatment Center, Inc. Of?ce of Refugee Resettlement Admission Packet Affidavit Authorizing Consent to Medical Care Consent to Administer Prescription Medications Consent to Administer Non-prescription (OTC) Medications State of TEXAS BEFORE ME, the undersigned authority, on this day personally appeared 1? who after being duly sworn by me, on his/her oath did say Parent, Guardian, or Conservator Name ram andlamthe mother Parent, Guardian, or Conservator Name Relationship to Client of who is in the care of Shiloh Treatment Center. Client Name if at any time such child or ward of mine should require medical or related care while in the care of Shiloh Treatment Center (Shiloh), consent to the administration of necessary medical or related care, including any appropriate medications, and authorize any approved representative of Shiloh to give consent to any doctor, emergency medical service, hospital, or other medical facility to provide medical or related care to such child or ward. I further give my permission for Shiloh to administer such medications that may be prescribed or recommended by medical personnel treating my child or ward. I understand that i will be noti?ed about medical care and the prescription of medication. Signature of Parent, Guardian, or Conservator 9/06/18 3:30 pm Case Manager contacted minor's mother, P-, and received verbal consent for medical care. SWORN TO AN SUBSCRIBED before me, the day of ,20 Signature of Notary Public Printed Name of Notary Public Notary Public for: County Rev. 09/10 File in Master Chart I-1 Case Document 515 Filed 11/02/18 Page 21 of 31 Page ID #:25697 Shiloh Treatment Center, Inc. Consent to Treatment with Medication The chem, Abilify (Aripiprazole) The parent or guardian, has received a complete explanation of has received a new medication (Name of medication) The explanation was_glv_en to the parent or responsible party In a simple, nontechnical lame and included: _(Check all as accorleished.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s), including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment. if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). 0 Any side effects which are known to frequently occur in most individuals a Any side effects to which the individual may be predisposed The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroieptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. [51135 El BEBE An offer to answer any questions concerning the treatment. have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral explanation Ci Printed material Other: have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medications(s) for which i have given consent. Based upon this explanation. I hereby consent to treatment with the above medication(s). I understand that i may withdraw this consent at any time. Method of communication: Phone in person El Fax Mail 09/24/2018 Case Manager Representative Signatur Date Relationship to client Physician. NP. PA. RN or LVN providing explanation Comments: Information provided by Case Manager- WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05/08 Case Document 515 Filed 11/02/18 Page 22 of 31 Page ID #:25698 Shiloh Treatment Center, inc. Consent to Treatment with Medication The client, has received a new medication The parent or guardian, has received a complete explanation of Lithobid (Lithium Carbonate ER) (Name of medication) The explanation was given to the parent or responsible party in a simple, nontechnical language and included: (Check all as accomplished.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medicationis). The probable health and mental health consequances of not taking medication(s), including occurrence. increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment. if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). 0 Any side effects which are known to frequently occur in most individuals 3. 0 Any side effects to which the Individual may be predisposed The nature and possibie occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroleptic medication In large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. EIISIS IS An offer to answer any questions concerning the treatment. I have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral expianation Printed material Other: I have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medications(s) for which I have given consent. Based upon this explanation, I hereby consent to treatment with the above medlcation(s). I understand that I may withdraw this consent at any time. Method of communication: Phone In person El Fax Mail 08/ 31 I201 8 Date treatment to be in: 09/24/2018 Case Manager Date Relationship to client Representative Signatur Physician. NP. PA. RN or LVN providing explanation Information provided by Case Manager, Comments: WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05/08 Case Document 515 Filed 11/02/18 Page 23 of 31 Page ID #:25699 Shiloh Treatment Center. Inc. Consent to Treatment with Medication The chem. . has received a new medication The parent or guardian, has received a complete explanation of Zoloft (Sertraline) (Name of medication) The explanation was glv_en to the parent or responsible party in a simplemontechnical languag?nd Included: {Check_all as accom?shed.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s), including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment, if any. that could reasonably be expected to achieve the same benefits as the medication{s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). - Any side effects which are known to frequently occur in most individuals Any side effects to which the individual may be predisposed The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroleptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. EH35 5 SEE SENSE An offer to answer any questions concerning the treatment. I have received a complete explanation of the medicationts) by means of: (Check all appropriate methods) Oral explanation Printed meteriat El Other: I have received the Consent to Treatment with Medication form or Information contained within that summarizes speci?c information regarding the medications(s) for which i have given consent. Based upon this explanation, I hereby consent to treatment with the above medication(s). I understand that I may withdraw this consent at any time. Method of communication: Phone In person Fax Mail Date t, 08/22/2018 09/24/2018 Case Manager Representative Signatur Date Relationship to client Physician, NP, PA. RN or LVN providing explanation Comments; Information provided by Case Manager,? WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION I formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05108 Shiloh Treatment Center, Inc. Office of Refugee Resettlement Paquete de Admisi?n Acuerdo de Ubicaci?n Por medio de la presente solicito que sea ubicado en el programa de Nombre del Cllente Eltratamiento subagudo El tratamiento residencial El tratamiento diurno (hospitalizaci?n parcial) en el Centro de Tratamiento Shiloh por aproximadamente 50 Mdias/ semanas/ meses para el tratamiento de (enumere las razones de la ubicacibn): self-injurious behaviors. suicidal ideations, and mood instability. La siguiente informaci?n encontrada en el Manual del Estudiante ha sido revisada a mi satisfacci?n: 1. Derechos individuales 4. Procedimientos de disciplina 2. Programaci?n servicios 5. Derechos del Cliente 3. Procedimientos de Visita 6. Responsabilidades Financieras Responsabilidad Flnaneiera El otorgante es responsable de pagar todas las necesidades m?dicas. incluyendo pero sin restricci?n a honorarios m?dicos, medicinas, trabajos dentales, lentes de aumento pruebas de laboratorio prescritas por un m?dico. Tratamiento Entiendo que esta instalaci?n coordinara un plan de tratamiento individualizado para el cliente. Evaluaci?n Entiendo que esta instalaci?n proveera una evaluaci?n, supervisi?n seguimiento continuo por la duraci?n del cuidado necesario. Fotografias videos Entiendo que esta instalacion puede tomar fotos del cliente para el uso personal del cliente para propOSitos de identificaci?n. Tambi?n entiendo que esta instalaci?n puede grabar videos del cliente en areas comunes de Ios hogares de ensenanza para monitorear las interacciones del personal el cliente. Solo para Tratamiento Subagudo Residencial Hogar Entiendo que en esta instalaci?n el personal estara presente en el hogar a todo momento asumira la responsabilidad de su cuidado. Vestimenta Todos los articulos personales ropa seran provistos por la instalaci?n en la entrada del programa sera reemplazada cuando sea necesario. He leldo entendido las politicas para la admision en el Centre de Tratamiento Shiloh Treatment Center. He acordado la admisi?n el Fecha 9/06/18 2:27 pm Case Manager contacted the minor?s mother but there was no answer. 9/ 10/ 18 11:07 am Case Manager contacted the minor's mother and received received verbal consent for placement. Padres, Representante 0 Persona Responsable Fecha Cliente Fecha g. Q/io/I? Te 90 Date Rev. 03/14 Copy to Medical Chart and Travel Folder C-1 Case Document 515 Filed 11/02/18 Page 25 of 31 Page ID #:25701 Shiloh Treatment Center, Inc. Office of Refugee Resettlement Admission Packet Affidavit Authorizing Consent to Medical Care Consent to Administer Prescription Medications Consent to Administer Non-prescription (OTC) Medications State of TEXAS BEFORE ME, the undersigned authority, on this day personally appeared who after being duly sworn by me, on his/her oath did say Parent, Guardian, or Conservator Name i am and I am the Mother Parent, Guardian, or Conservator Name Relationship to Client of who is in the care of Shiloh Treatment Center. Client Name If at any time such child or ward of mine should require medical or related care while in the care of Shiloh Treatment Center (Shiloh), consent to the administration of necessary medical or related care, including any appropriate medications, and authorize any approved representative of Shiloh to give consent to any doctor, emergency medical service, hospital, or other medical facility to provide medical or related care to such child or ward. I further give my permission for Shiloh to administer such medications that may be prescribed or recommended by medical personnel treating my child or ward. I understand that I will be notified about medical care and the prescription of medication. Signature of Parent, Guardian, or Conservator 9/06/18 2:27 pm Case Manager contacted the minor's mother but there was no answer. 9/10/18 11:07 am Case Manager contacted the minor's mother and received verbal consent for medical care. SWORN TO AN SUBSCRIBED before me, the day of .20 Signature of Notary Public Printed Name of Notary Public Notary Public for: County Rev. 09/10 File in Travel Folder I-3 Case Document 515 Filed 11/02/18 Page 26 of 31 Page ID #:25702 Shiloh Treatment Center, Inc. Consent to Treatment with Medication The client. has received a new medication .9- Abilify (Aripiprazole) The parent or guardian. has received a complete explanation of (Name of medication) The explanation was given to the parent or responsible party in a simple, nontechnical language and included: (Check all as accomplished.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medicationts). The probable health and mental health consequences of not taking medication(s), including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment. if any, that could reasonably be expected to achieve the same bene?ts as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medicationts). The fact that side effects of varying degrees of severity are a risk of taking any medicationts). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). - Any side effects which are known to frequently occur in most individuals 0 Any side effects to which the individual may be predisposed The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroleptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. An offer to answer any questions concerning the treatment. ESE EllSlEl have received a complete explanation of the medication(s) by means of: (Check all approprlate methods) Oral explanation Printed material Other: I have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medications(s) for which i have given consent. Based upon this explanation, i hereby consent to treatment with the above medication(s). understand that may withdraw this consent at any time. Phone El In person Fax Mail 06/12/2018 Method of communication: Date treatment to begin: 09/24/2018 Case Manger Representative gimme Physician. NP. PA, RN or LVN providing explanation Comments; Information provided by Case Manager, WITH DRAWAL OF CONSENT To TREATMENT WITH MEDICATION formally withdraw my consent to treatment with Date Relationship to client (Name of medication) Representative Signature Date \Mtness Date Revised 05/08 Case Document 515 Filed 11/02/18 Page 27 of 31 Page ID #:25703 Shiloh Treatment Center. inc. Consent to Treatment with Medication The client, . has received a new medication The parent or guardian, has received a complete explanation of Buspar (Buspirone) (Name of medication) The explanation was given to the parent or responsible party In a simple, nontechnical language and Included: (Check all as accomplished.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s). including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medicationsts). - Any side effects which are known to frequently occur in most individuals 0 Any side effects to which the individual may be predisposed The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroieptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. An offer to answer any questions concerning the treatment. SEE IS EIHEI I have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral explanation Printed material [3 Other: I have received the Consent to Treatment with Medication form or information contained within that summarizes specific information regarding the medications(s) for which i have given consent. Based upon this explanation. I hereby consent to treatment with the above medication(s). i understand that I may withdraw this consent at any time. Method of communication: phone In person Fax Ma" Date treatment to begin: 09/ 05/ 201 3 4 09/24/2018 Case Manger Representative rgnature Date Relationship to client Physician. NP. PA. RN or LVN providing explanation Comments; Information provided by Case Manager,? WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION I formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05/08 Case Document 515 Filed 11/02/18 Page 28 of 31 Page ID #:25704 V, . Shiloh Treatment Center, Inc. Consent to Treatment with Medication The client, . has received a new medication The parent or guardian, has received a complete explanation of Zoloft (Sertraline) (Name of medication) The explanation was given to the parent or responsible party in a simple, nontechnical language and included: (Check all as accomplished.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s), including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same bene?ts as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). Any side effects which are known to frequently occur in most individuals 0 Any side effects to which the individual may be predisposed The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroleptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. SEE [3 .. @3513 An offer to answer any questions concerning the treatment. have received a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral explanation Printed material Other: have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medicationsts) for which have given consent. Based upon this explanation, I hereby consent to treatment with the above medication(s). understand that I may withdraw this consent at any time. Method of communication: Phone n person Fax Ma? Date treatment to begin: 06/1 3/2018 4 09/24/2018 Case Manger Representati Signature Date Relationship to client Physician. NP. PA, RN or LVN providing explanation Comments; Information provided by Case Manager_ WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION formally withdraw my consent to treatment with (Name ofmedication) Representative Signature Date Witness Date Revised 05i08 Case Document 515 Filed 11/02/18 Page 29 of 31 Page ID #:25705 Shiloh Treatment Center. Inc. Office of Refugee Resettlement Paquete de Admisi?n Acuerdo de Ubicaci?n Por medio de la presente solicito que sea ubicado en el programa de Nombre del Cliente Ki tratamiento subagudo El tratamiento residencial El tratamiento diurno (hospitalizacion parcial) en el Centro de Tratamiento Shiloh por aproximadamente 5Q [11 diasl [j semanas/ meses para el tratamiento de (enumere las razones de la ubicaci?n): depression and anxiety leading to verbal aggression, grief/loss from the separation of her child, and possible gang affiliation. La siguiente informaci?n encontrada en el Manual del Estudiante ha sido revisada a mi satisfacci?n: 1. Derechos individuales 4. Procedimientos de disciplina 2. Programacion servicios 5. Derechos del Cliente 3. Procedimientos de Visita 6. Responsabilidades Financieras Responsabilidad Financiera El otorgante es responsable de pagar todas las necesidades m?dicas, incluyendo pero sin restriccion a honorarios medicos, medicines, trabajos dentales, lentes de aumento pruebas de laboratorio prescritas por un m?dico. Tratamiento Entiendo que esta instalaci?n coordinara un plan de tratamiento individualizado para el cliente. Evaluaci?n Entiendo que esta instalacion proveera una evaluaci?n, supervisi?n seguimiento continuo por la duracion del cuidado necesario. Fotografias videos Entiendo que esta instalaci?n puede tomar fotos del cliente para el uso personal del cliente para prop?sitos de identificaci?n. Tambi?n entiendo que esta instalacion puede grabar videos del Cliente en areas comunes de los hogares de ense?anza para monitorear las interacciones del personal el cliente. Solo para Tratamiento Subagudo Residencial Hogar Entiendo que en esta instalacion el personal estara presente en el hogar a todo momento asumira la responsabilidad de su cuidado. Vestimenta Todos los articulos personales ropa ser?n provistos por la instalacion en la entrada del programa sera reemplazada cuando sea necesario. He leido entendido las politicas para la admision en el Centro de Tratamiento Shiloh Treatment Center. He acordado la admision el Fecha 9/06/18 3:38 pm Case Manager contacted minor's father, 3-, and received verbal consent for placement. Padres, Representante 0 Persona Responsable Fecha ente Fecha 01 etc i i estigo Date Rev. 03/14 Copy to Medical Chart and Travel Folder C-1 Case Document 515 Filed 11/02/18 Page 30 of 31 Page ID #:25706 Shiloh Treatment Center, Inc. Office of Refugee Resettlement Admission Packet Affidavit Authorizing Consent to Medical Care Consent to Administer Prescription Medications Consent to Administer Non-prescription (OTC) Medications State of TEXAS BEFORE ME, the undersigned authority, on this day personally appeared S- who after being duly sworn by me, on his/her oath did say Parent, Guardian, or Conservator Name lam S- and I am the Father Parent, Guardian, or Conservator Name Relationship to Client of who is in the care of Shiloh Treatment Center. Client Name if at any time such child or ward of mine should require medical or related care while in the care of Shiloh Treatment Center (Shiloh), consent to the administration of necessary medical or related care, including any appropriate medications, and authorize any approved representative of Shiloh to give consent to any doctor, emergency medical service, hospital, or other medical facility to provide medical or related care to such child or ward. I further give my permission for Shiloh to administer such medications that may be prescribed or recommended by medical personnel treating my child or ward. i understand that I will be noti?ed about medical care and the prescription of medication. Signature of Parent, Guardian, or Conservator 9/06/18 3:38 pm Case Manager contacted minor's father, 8-, and received verbal consent for medical care. SWORN TO AN SUBSCRIBED before me, the day of ,20 Signature of Notary Public Printed Name of Notary Public Notary Public for: County Rev. 09/10 File in Master Chan? Case Document 515 Filed 11/02/18 Page 31 of 31 Page ID #:25707 Shiloh Treatment Center, Inc. Consent to Treatment with Medication The client. . has received a new medication The parent or guardian, S- has received a complete explanation of LEMPRO (ESCITALOPRAM) (Name of medication) The explanation was given to the parent or responsible party in a simple, nontechnical language and included: (Check all as accomplished.) The client's diagnosis and nature of his or her mental illness. An explanation of the purpose of the medication. The expected beneficial effects of his or her condition as a result of treatment with medication(s). The probable health and mental health consequences of not taking medication(s), including occurrence, increase or recurrence of of mental illness. The existence of generally accepted alternative forms of treatment, if any, that could reasonably be expected to achieve the same benefits as the medication(s) and why the physician rejects the alternative treatment. A description of the proposed course of treatment with the medication(s). The fact that side effects of varying degrees of severity are a risk of taking any medication(s). The risk of relevant side effects of varying degrees of severity associated with taking medications(s). 0 Any side effects which are known to frequently occur in most individuals 0 Any side effects to which the individual may be predisposed i The nature and possible occurrence of the potentially irreversible of tardive dyskinesia in some individuals taking neuroieptic medication in large dosages and/or long periods of time. The need to advise staff immediately if any of these side effects occur. An instruction that the individual may withdraw consent at any time without negative actions on the part of the staff. An offer to answer any questions concerning the treatment. have receivad a complete explanation of the medication(s) by means of: (Check all appropriate methods) Oral explanation Printed materiai El Other. have received the Consent to Treatment with Medication form or information contained within that summarizes speci?c information regarding the medicationsis) for which i have given consent. Based upon this explanation. I hereby consent 3 to treatment with the above medication(s). I understand that I may withdraw this consent at any time. Method of communication: Phone in person Fax Mail 08/22/2018 09/26/2018 Case Manager Representative Signature Date Relationship to client Physician, NP. PA, RN or LVN providing explanation Commems; Informed by Case Manager,? WITHDRAWAL OF CONSENT TO TREATMENT WITH MEDICATION formally withdraw my consent to treatment with (Name of medication) Representative Signature Date Witness Date Revised 05/08