Healthcare Behavioral Trip Form

HEALTHCARE BEHAVIORAL TRIP FORM

Patient Information

Date of Birth:    Gender: Male Female Other

Insurance Information

Trip Details

Trip Date:    Departure Time:    Estimated Return Time:

Therapeutic / Treatment Appointment
Community Integration / Skills Building
Recreational / Social
Medical Appointment
Other (explain below)

Behavioral History and Risk Assessment

Known Triggers / Early Warning Signs:

Current Behavioral Status: Stable Elevated/Agitated Aggressive Suicidal/Homicidal Ideation

Seizure History: Yes No

Medications & Health Supports During Trip

Authorization for staff to administer medication as prescribed: Yes No

Safety Plan & Interventions

De-escalation strategies to be used (verbal redirection, removal from stimulus, etc.). Physical restraint or seclusion will only be used if the patient poses an immediate risk of serious harm to self or others and only to the minimum degree necessary.

Emergency Medical Treatment & Transport Authorization

I authorize supervising staff and authorized agents to obtain emergency medical treatment and to arrange transport to an appropriate medical facility should it become necessary during the trip. I understand staff will make reasonable attempts to contact the emergency contact and treating clinician prior to non-urgent medical interventions.

I authorize release of necessary health information to medical personnel to facilitate emergency care: Yes No

HIPAA / Privacy Acknowledgment

By signing below I acknowledge that I have been informed that my protected health information may be shared with staff and emergency personnel as necessary to facilitate safe transport, care, and treatment during the trip, and that such disclosures are limited to the minimum necessary information.

Acknowledgment of Notice: I acknowledge and consent

Authorization Details & Limitations

This authorization permits the patient to participate in the described trip and authorizes staff actions as set forth above. I understand I may revoke this authorization at any time in writing, except to the extent that action has already been taken in reliance upon it.

Acknowledgment and Signature

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand the risks associated with participation in off-site activities and that staff will exercise professional judgment to protect health and safety. I accept responsibility for notifying supervising staff of any changes in health status prior to departure.

Sign Now