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Application Date:

How did you hear about us?


1. APPLICANT INFORMATION

Name of Child:

Social Security Number:

Age:

Birthdate:

Birthplace:

Religious Affiliation:

Ethnicity:

Is the child presently living at home?

Explain conditions in which your child is living at home?

Height:

Weight:

Does your child have any tattoos and/or piercings?

Scars:

List names and phone numbers of relatives or friends your child might try to contact:

Current behavior:

Emergency Contact Information:
Who should we contact in case of emergency (Home, Cell Phone Number and Email)


2. PREVIOUS PROGRAMSIf this section does not apply to your child or family please skip.

Has your child had previous placements outside of home?

Facility Name:

Date:

Reason:

Facility Name:

Date:

Reason:

Facility Name:

Date:

Reason:


3. PARENT INFORMATION

Father's Name:
Write N/A if "unknown"

Deceased:

If "deceased" please explain cause of death if known:

Age:

Occupation:

Address:

Home Phone:

Work Phone:

Cell Phone:

Email:

Best method and time to contact you:


3.1 PARENT INFORMATION II

Mothers Name:
Write N/A if "unknown"

Deceased:

If "deceased" please explain cause of death if known:

Age:

Occupation:

Address:

Home Phone:

Work Phone:

Cell Phone:

Email:

Best method and time to contact you:


3.2 PARENT INFORMATION IIIIf this section does not apply to your child or family please skip.

Does the child have a Stepfather

YESNO

Stepfather's Name:
Write NA if "unknown"

Deceased:

If "deceased" please explain cause of death if known:

Age:

Occupation:

Address:

Home Phone:

Work Phone:

Cell Phone:

Email:

Best method and time to contact you:


3.4 PARENT INFORMATION IVIf this section does not apply to your child or family please skip.

Does the child have a Stepmother?

Stepmother's Name:
Write NA if "unknown"

Deceased:

If "deceased" please explain cause of death if known:

Age:

Occupation:

Address:

Home Phone:

Work Phone:

Cell Phone:

Email:

Best method and time to contact you:


4. FAMILY DYNAMICS

Immediate Family members:
List name, age and relation to child

Parents Martial Status:

Any past or current custody battles?

Who has legal custody of the child?

If divorced or separated, please explain how this has impacted the child:

Has either parent remarried?

Please explain if remarriage has been an issue with your child
Briefly explain how it has impacted your child


4.1 FAMILY RELATIONSHIPS

Father:

Mother:

Stepfather:

Stepmother:

Siblings:

Other:

Please explain any present medical conditions of family members which may affect your child
List past and present conditions

Describe relationship with each of the following


5. ADOPTIONIf this section does not apply to your child or family please skip.

Was your child adopted?

Date of adoption:

Age at moment of adoption:

Country/Place of Adoption:

Previous Adoption Home:

Please explain any special circumstances or issues leading up to adoption:

Add any information you may have about biological parents:
Write NA if not available

Does child have or has had contact with biological relatives?

Explain involvement with biological relatives:


6. CHILD'S CHARACTER AND PERSONALITY I

Child's Personality I
Select all that apply

Please explain in more detail:
For Personality I

Child's Personality II:
Select all that apply

Please explain in more detail:
For Personality II

Child's Personality III:
Select all that apply

Please explain in more detail:
For Personality III

Do any of the following apply to your child?
Select all that apply

Please explain in more detail:


6.1 CHILD'S CHARACTER AND PERSONALITY II

Has your child displayed aggressive or violent behavior

Explain:

Has your child had any involvement with the legal system?

Explain:

Has your child ever talked about, threatened or attempted suicide?

Explain:
Please mention number of attempts and how they were done

Does your child have a history of self-mutilation?:
Cutting, bruising, etc.

If you answered YES please explain

Has your child had any extreme changes in mood or behavior?

If you answered YES, please explain:

Has your child shown or discussed with you any abnormal thoughts?

If you answered YES please explain:

Has your child ever run away?

If you answered YES, to run away please explain:
Please explain how many times, for how long, distance traveled, who did he/she stayed with, and any illegal activity, etc.


6.2 MEDICAL INFORMATION

Who is currently treating your child?
(Physicians, Psychiatrist, Psychologists, etc.) List Names and Dates

Is your child currently on medication?

Please list medications your child has taken in the past:
List when the treatment began and when it was discontinued

Please list current medications your child is on:
List medication, reason for it and doses. Also list date when child began taking it

Does your child suffer any medical condition we should be aware of?
Diabetes, Heart Problems, Contagious Diseases, Severe Allergies, etc. Please Explain


6.3 SUBSTANCE ABUSE HISTORYIf this section does not apply to your child or family please skip.

Does your child have any substance abuse problem?

Is your child addicted to any of the following substances?
Select all that apply

If other, please explain:

Is there a history of Family Drug Use:

If you answered yes, please explain


7. SPECIFIC HISTORY OF ABUSEIf this section does not apply to your child or family please skip.

Is your child a Victim and/or Offender:
Include Bullying, Neglect, Physical abuse & Verbal or Emotional Abuse.

If other, please explain:

Select all that apply for your child (Victim)

Select all that apply for your child (Offender)

Has any legal measure been taken:

If answer is "yes" please explain legal measures taken:

What is the child's behavior and attitude exhibited in regards to the situation
Please explain

Please explain degree of family involvement


7.1 SEXUAL HISTORY

Has your child been sexually active?

If answer is "yes" please explain

Has your child had any sexual problems?

Please explain sexual problems
Write NA if it doesn't apply

Has your child had any sexual identity issues

Please explain Sexual Identity issues
Answer NA if it doesn't apply

If child has been sexually abused, please explain


8. SOCIAL HISTORY

Birth to six years old:

Six to Twelve years old:

Twelve to present:

Does your child make friends easily or do they have difficulty relating to others?

If other, please explain

Does your child like to be alone?

Are your child's friends mostly younger, older or the same age?

Are your child's friends usually the same sex or opposite sex?

Has your child recently changed friend group or stopped hanging out with current friends?

Please explain if you answered yes:

Please explain your feelings towards your child's friends


9. EDUCATIONAL HISTORY

Elementary School:

Middle School:

High School:

Has your child had any difficulties in school?

Please explain:

Does your child have an IEP (Individualized Education Plan) or special education plan?

Please Explain IEP or SEP:

Has your child been diagnosed with Dyslexia, ADD, ADHD, ODD or any other diagnosis?

Please explain diagnosis

Does your child have any of the following

If other, please explain:

Please explain hearing, sight, speech impediment, etc.

Has your child repeated a grade level?

Please explain what grade level and why

Has your child been suspended or expelled?

Please explain reasons for suspension or being expelled:

If your child stopped attending, please explain why:

What are your child's current academic needs?
Please explain


10. ADDITIONAL INFORMATION

Have there been any circumstances in the child's life which have been difficult for him/her to accept?
Explain

Have there been any deaths in the family or friends that have greatly impacted your child?
Explain

What does your child believe his current problems are?
Explain

What are your expectations of placement at our Academy?
Explain

What do you see as your child's estimated stay at our Academy?
Explain

At our Academy we know that parent involvement in the child's program is essential. Please explain how you plan to be involved?
Explain

If your child knows they're being placed at our Academy, what is their perception of it?
Explain


11. SPECIAL NEEDS AND STRENGTHS

Physical:
Please explain Needs and Strengths

Family:
Please explain Needs and Strengths

Educational:
Please explain Needs and Strengths

Social:
Please explain Needs and Strengths

Psychological:
Please explain Needs and Strengths

Spiritual:
Please explain Needs and Strengths