Admission Application

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Easter York
10 years ago
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1 RESIDENT INFORMATION Ethnicity: Language: Religion: Age: Current Placement - Discharge Plan: Physical Description: HT: WT: BIOLOGICAL Mother s Information Name: Place of Employment: Is Parent Legal Guardian? Y N Are Parental Rights Terminated? Y N Is Child Adopted? Y N Is Parent Involved? Y N BIOLOGICAL Father s Information Name: Place of Employment: Is Parent Legal Guardian? Y N Are Parental Rights Terminated? Y N Is Child Adopted? Y N Is Parent Involved? Y N Comment: Comment: LEGAL GUARDIAN INFORMATION IF OTHER THAN PARENT Agency: REFERRAL SOURCE INFORMATION Referral Source: School Parent Agency/County Other County of Referral: Name of Referral Source: Name & Title (Case Manager, Case Worker, ICC Coordinator, etc.): Address : Cell: FUNDING Medicaid Title IV-E CSA Adoption Subsidy HMO Cell: Medicaid Insurance #: Social Security #: Private Ins. Company: Private Ins. Member #: Ins. Member s Name: Date of Birth: Rev 10/21/14 Page 1 of 5

Y N Are Parental Rights Terminated? Y N Is Child Adopted? Y N Is Parent Involved?

2 FUNDING/PLACING AGENCY INFORMATION Placing Agency/County (Agency FUNDING Placement): CSA Coordinator: OTHER INVOLVEMENT (Step-Parent, Foster Parent, GAL, CASA Worker, etc.) MENTAL HEALTH INFORMATION Reason for Referral: Abuse History: Physical Neglect Sexual Emotional Clinical Assessments Requested: EDUCATIONAL INFORMATION Current Grade: Local Education Agency (LEA): Special Services: IEP: Yes No Current School: Legal Involvement: Yes No If Yes, Explain: Probation Officer CHILD AND FAMILY INFORMATION Probation Officer: Is there a Protective Order in Place? Yes No Is there any Restrictive Contact? Yes No Explain: Explain: Does Family have reliable transportation to attend Therapy/Treatment/Meetings? Yes No Rev 10/21/14 Page 2 of 5

Agency (LEA): Special Services: IEP: Yes No Current School: Legal Involvement: Yes No If Yes, Explain: Probation Officer CHILD AND FAMILY INFORMATION Probation Officer: Is there a

3 HEALTH AND NUTRITION INFORMATION Childhelp reserves the right to not admit a child who presents with a communicable disease at the time of admission, unless our Medical Director certifies that our facility is capable of providing care to the child without jeopardizing residents and staff. Please advise the Admissions Director of any Communicable Disease - (i.e., Flu, Strep, MRSA, Lice, HIV, Hep. A, B, or C, etc.) your child may have prior to the time of Admission Current Immunizations? Does child wear orthodontic braces? Does child wear glasses? Diagnosed Allergies -including drug/food allergy/intolerance: Provide reports that support diagnosed allergy: Any noted nutritional problems? Doctor Ordered Therapeutic Diet? Yes No CURRENT PHYSICIAN INFORMATION Doctor Name: Dentist Name: Last Appt: Last Appt: Other Specialist: Last Appt: DEVELOPMENTAL HISTORY Please indicate if there were any concerns with the following: Born at Months. Normal Delivery? Yes No If no, explain Complications at Birth? Yes No If yes, explain Concerns with Gross Motor Skills? Yes No If yes, explain Concerns with Fine Motor Skills? Yes No If yes, explain Concerns with Speech Development? Yes No If yes, explain What age was Child Toilet Trained? OTHER INFORMATION Likes: Dislikes: Indicators of Success at Home/Other Placement: History of Unsubstantiated Claims? Rev 10/21/14 Page 3 of 5

A, B, or C, etc.) your child may have prior to the time of Admission Current Immunizations? Does child wear orthodontic braces? Does child wear glasses?

4 Significant Behavior Information - Place a check mark ( ) next to behaviors that are occurring Significant Behaviors and Frequency of most recent occurrence (indicate frequency with daily, 4-5 days a week or 1-3 days a week ) Sexually Inappropriate Freq: Suicidal Ideation Freq: Homicidal Ideation Freq: Fire Setting Freq: Temper Outbursts Freq: Self-harming Behaviors Freq: Physical Aggression Freq: Animal Cruelty Freq: Verbal Aggression Freq: Lying Freq: Stealing Freq: Property Destruction Freq: Enuresis Freq: Runs Away Freq: Encopresis Freq: Wanders a t Night Freq: Nightmares Freq: Depressed/Anxious Symptoms Freq: Poor Hygiene Freq: Oppositional Defiant Behaviors Freq: TREATMENT SERVICES AND PLACEMENT HISTORY FOR PAST YEAR Name of Service/Placement Type of Service/Placement Dates of Service (mm/dd/yy - mm/dd/yy) Reason for Removal Rev 10/21/14 Page 4 of 5

Freq: Animal Cruelty Freq: Verbal Aggression Freq: Lying Freq: Stealing Freq: Property Destruction Freq: Enuresis Freq: Runs Away Freq: Encopresis Freq: Wanders a t Night Freq: Nightmares Freq:

5 MEDICATION RECONCILIATION FORM Current Medication Name Dosage Schedule Medications Tried in the Past and Effects Dosage Schedule Information Provided By: Relationship: Rev 10/21/14 Page 5 of 5

Admission Application

Admission Application Kids in Focus Girls in Focus Little Kids in Focus Little Kids in Focus II Kids in Focus II Instructions: When completing the application please do not leave blanks. If the requested