DJJ Form HS023 "Personal and Health-Related Information" - Florida

What Is DJJ Form HS023?

This is a legal form that was released by the Florida Department of Juvenile Justice - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2006;
  • The latest edition provided by the Florida Department of Juvenile Justice;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DJJ Form HS023 by clicking the link below or browse more documents and templates provided by the Florida Department of Juvenile Justice.

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Download DJJ Form HS023 "Personal and Health-Related Information" - Florida

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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
PERSONAL AND HEALTH-RELATED INFORMATION
F
N
: ___________________________________ D
: _________________
ACILITY
AME
ATE
DJJID #__________________________
Y
P
I
OUTH
S
ERSONAL
NFORMATION
N
Y
:
____________________
___________
_________________________________
AME OF
OUTH
First
Middle
Last
Youth First Alias:
_____________________________________________________________________
Date of Birth:
____________ Age: ____________ Eyes: __________ Hair: ___________________
Race:
____________ Religious Preference: ______________________________________
Youth Address:
_____________________________
____________ _____
________ ________
Street Address
City
State
Zip Code
County
Telephone # (home): _______________________ Telephone # (mobile): __________________________
School Information: _______________________
___________
________ Grade completed: _______
School Name
City/State
County
P
/G
I
ARENT
UARDIAN
NFORMATION
Name of Parent/Guardian_____________
___________
_________________
____________
First
Middle
Last
Relationship
Address:
_______________________________ __________ ______ ________ ________
Street Address
City
State
Zip Code County
Telephone # (home): _______________________ Telephone # (mobile): __________________________
H
C
P
I
EALTH
ARE
ROVIDER
NFORMATION
Physician
Name of Primary Care Physician: ______________________ ___________________________________
First
Last
Address:
____________________________
________________
_________
_________
Street Address
City
State
Zip Code
Telephone # (office): ____________________ Telephone # (mobile/pager): ________________________
Specialist
Specialist Name:
__________________
_____________________________ ________________
First
Last
Specialty
Address: ______________________________
_____________
________
__________
Street Address
City
State
Zip Code
Telephone # (office): _____________________ Telephone # (mobile/pager): _______________________
023
FORM
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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
PERSONAL AND HEALTH-RELATED INFORMATION
F
N
: ___________________________________ D
: _________________
ACILITY
AME
ATE
DJJID #__________________________
Y
P
I
OUTH
S
ERSONAL
NFORMATION
N
Y
:
____________________
___________
_________________________________
AME OF
OUTH
First
Middle
Last
Youth First Alias:
_____________________________________________________________________
Date of Birth:
____________ Age: ____________ Eyes: __________ Hair: ___________________
Race:
____________ Religious Preference: ______________________________________
Youth Address:
_____________________________
____________ _____
________ ________
Street Address
City
State
Zip Code
County
Telephone # (home): _______________________ Telephone # (mobile): __________________________
School Information: _______________________
___________
________ Grade completed: _______
School Name
City/State
County
P
/G
I
ARENT
UARDIAN
NFORMATION
Name of Parent/Guardian_____________
___________
_________________
____________
First
Middle
Last
Relationship
Address:
_______________________________ __________ ______ ________ ________
Street Address
City
State
Zip Code County
Telephone # (home): _______________________ Telephone # (mobile): __________________________
H
C
P
I
EALTH
ARE
ROVIDER
NFORMATION
Physician
Name of Primary Care Physician: ______________________ ___________________________________
First
Last
Address:
____________________________
________________
_________
_________
Street Address
City
State
Zip Code
Telephone # (office): ____________________ Telephone # (mobile/pager): ________________________
Specialist
Specialist Name:
__________________
_____________________________ ________________
First
Last
Specialty
Address: ______________________________
_____________
________
__________
Street Address
City
State
Zip Code
Telephone # (office): _____________________ Telephone # (mobile/pager): _______________________
023
FORM
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63M-2
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FLORIDA DEPARTMENT OF JUVENILE JUSTICE
Dentist
Dentist Name: _________________________
___________________________________________
First
Last
Address: _______________________________
__________________ ______ ___________
Street Address
City
State
Zip Code
Telephone # (office): _____________________ Telephone # (mobile/pager): ______________________
M
H
P
I
ENTAL
EALTH
ROVIDER
NFORMATION
Provider Name: ___________________
___________________________________ _____________
First
Last
Title
Address: _____________________________ _________________
________ ___________
Street Address
City
State
Zip Code
Telephone # (office): _____________________ Telephone # (mobile/pager): _______________________
C
H
P
I
OMMUNITY
EALTH
ROVIDERS
NFORMATION
Preferred Hospital: ___________________________________________ Last inpatient stay: ___________
Date
Preferred Mental Health Facility: _________________________________ Last inpatient stay: ___________
Date
County Health Department: _____________________________________ _____________ ___________
Name
County
State
H
I
I
EALTH
NSURANCE
NFORMATION
N
ONE
Insurance Company: ____________________________________________________________________
Name of Company
Insurance Address:
________________________________________ ___________ _____ ________
Street Address
City
State
Zip code
Telephone Number: _____________________________________________________________________
(Area code) number
Policy Information:
_______________________ _________________ ____________ ______________
Insured Name
Insured SSN
Insured DOB
Relationship
_________________________ _____________________________ ____________
Insurance ID #
Policy #
Group #
N
: P
.
OTE
LEASE PROVIDE A COPY OF INSURANCE CARD TO FILE IN INDIVIDUAL HEALTH CARE RECORD
M
I
I
EDICAID
NSURANCE
NFORMATION
N
OT APPLICABLE
Identification Number: __________________________________________
______________________
State Medicaid Number
State
_________________________________________
_______________________
Name of Medicaid Program
Case Manager Name
C
C
ASE
ONTACTS
____________________________________ ______________ _________________________________
Juvenile Probation Officer
Unit
Phone: Work and Mobile
P
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AGE
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. 10/06
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