Social Security # Date of Birth Age. Mailing Address City State Zip Code. Race Gender Height Weight Religious preference

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1 VCU ADMISSION APPLICATION (804) Fax: (804) SERVICE REQUESTED 30-Day Evaluation 15-Day Evaluation Child s Name (please print) Nickname Social Security # Date of Birth Age Mailing CHILD S PERSONAL INFORMATION Race Gender Height Weight Religious preference List what you think this child s problems are that need to be addressed at VTCC Describe how this child responds to other people when Sad: Happy: Angry: Frustrated: What are this child s major interests? Page 1 of 5

2 List everyone who lives with this child: Name Age Relationship to child Describe this child s recent history (any major adjustments, change of address, birth of a sibling, recent loss, victim of a crime or other important event): Has this child experienced any physical, emotional or sexual abuse? No Yes If yes, please describe what has happened to this child LEGAL STATUS Has this child ever been involved with juvenile court or have legal charges pending? No Yes If YES, what were the charges? Does this child have a probation officer? No Yes If YES, what is the PO s name: : Does this child have a Guardian Ad Litem? No Yes If YES, what is the Attorney s name? _ : MEDICAL INFORMATION Are this child s immunizations up to date? No Yes Documentation of the child s immunization record will be required at admission. Page 2 of 5

3 Does this child have any medical problems such as asthma, developmental disabilities, vision or hearing disabilities, physical disabilities, etc.? No Yes If YES, please explain how it affects them: List child s current medication(s): What other medications have been tried and why were they stopped? Does this child have any food restrictions, food allergies, or special diet requirements? No Yes If YES, please explain: Has this child ever had an unexpected reaction to medication(s)? No Yes If YES, which medication(s) and what happened : Does this child have any environmental allergies (pollen, dust, etc)? No Yes If YES, please explain: _ HEALTHCARE PROVIDERS Pediatrician/Primary Care Name Psychiatrist Name Therapist or Counselor Name Dentist Name Date of Last Dental Visit Documentation of the dental visit will be required on admission. Has this child been admitted to any out of home treatment programs? No Yes If YES, list below and send the treatment summaries with this application. Program Name Date Admitted Number of Days Program Name Date Admitted Number of Days Page 3 of 5

4 Has this child been admitted to any psychiatric hospital? No Yes If YES, list below and send the physician s discharge summaries for each hospitalization within the last 2 years with this application. SCHOOL INFORMATION Current School Name Grade Guidance Counselor or Teacher Name Does this child receive Special Education services or other special support services at school? No Yes If YES please describe those services Does this child have an IEP or 504 plan in place? No Yes If YES, the IEP must be submitted with this application. Has this child ever been suspended or expelled from school? No Yes If YES, explain why: Has this child ever repeated a grade? No Yes If YES, which grade(s)? What are this child s strengths and weaknesses at school? Has this child ever received Occupational Therapy services either privately or at school? No Yes If YES, list the provider s name below. Occupation Therapy Provider Name WHO IS THE PARENT OR LEGAL GUARDIAN? Mother (please print) Marital Status Home Cell Work Page 4 of 5

5 Father (please print) Marital Status Home Cell Work Legal guardian (if different from parent(s) _ Home Cell Work I authorize the following person(s) to be contacted in case of an emergency if I cannot be reached: Emergency Contact Name Relationship to Child Home Phone Other Phone Emergency Contact Name Relationship to Child Home Phone Other Phone INSURANCE INFORMATION Is this child covered by Virginia Medicaid? Yes No If YES, list the ID#: Date Medicaid was Eligible: Other Insurance (Name) ID# Insurance Subscriber s Name Relationship to Child Social Security # Date of Birth PLACING AGENCY INFORMATION (IF APPLICABLE) Agency Name Contact Person Relationship to Child Fax Number Contact Name for CSA Funding Is this child CSA mandated? Yes No Is this child Title IV-E eligible? Yes No Are parental rights terminated? Yes No I,, certify that I have the authority to make this application on behalf of this child and that the information furnished is true and complete to the best of my knowledge. Signature Relationship to child Date Phone Page 5 of 5

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