Application for Residential Admission

---

Residential Admission -- Monthly Financial Support for Child (note amounts for all that apply)
DFACS $	Social Security $	Foundation $
Family $	Veteran's Benefit $	Other Pension $
Grant $	Youth Services/DYS $	SSI $
Court Ordered Child Support $		Insurance $
Mental Health/Retardation/Substance Abuse $		Dept. of Education $
Other $		Total $

Residential Admission -- Reasons for Placement
Precipitating Events Requiring Placement:
Are there indications that this child has experienced (check ALL that apply): Sexual Abuse Physical Abuse Physical Neglect Incest Emotional Abuse Emotional Neglect Other: If so, has the abuse/neglect been reported to the authorities? Yes No
What are the reason(s) for the placement of this child? (check ALL that apply): Lack of Finances Legal Detainment of Child Family Break-up Death of a Parent Parental Drug Use Child's Drug Use Child's Behavioral Problems Child's Sexual Acting Out Child's Emotional Problems Parental Alcohol Abuse Child's Alcohol Abuse Child's Law Violations Physical Abuse Emotional Abuse Runaway Need for Shelter (homelessness) Lack of Parenting Skills Parental Physical Illness Divorce/Separation Parental Imprisonment Sexual Abuse Physical/Mental Disabilities Parental Mental Illness Step-Parent Conflict Other: Please list primary reasons:
Which of the following behaviors pertain to the child's past or present? (check ALL that apply): Runaway School Behavior Problems Fighting Sexual Acting Out Destructive of Property Temper Tantrums Violation of Curfews/Sneaking Out Alcohol or Drug Abuse Depression/Withdrawal Truancy Suicide Attempts or Threats Aerosol Sniffing Threats of Injury to Self Threats or Attempts to Harm Others Involvement in Satanism Firesetting Stealing Harmful to Animals Other: Explanation: Please list specifics (i.e. drugs used, behavior problems, etc.):

Residential Admission -- Family Information
Family status of parents (check the one that most closely describes the child's family): Married Parents Living Together Unmarried Parents Divorced Single Parent Separated Single Parent Unmarried Single Parent Widow(er)ed Single Parent Parent Deceased Biological Parent and Step-Parent Biological Parent and Partner Unspecified Unknown

Residential Admission -- Father's Information
Is Current Father... Birth-Father Adoptive-Father Step-Father
Father's Name: First Middle Last
SS# Date of Birth Birthplace:
Current Address: Street Apt. City State Zip
Home Telephone Work Telephone
Is Current Father... Living Dead Unknown
If Father is Dead: Date of Death Age Cause

Residential Admission -- Mother's Information
Is Current Mother... Birth-Mother Adoptive-Mother Step-Mother
Mother's Name: First Middle Last
SS# Date of Birth Birthplace:
Current Address: Street Apt. City State Zip
Home Telephone Work Telephone
Is Current Mother... Living Dead Unknown
If Mother is Dead: Date of Death Age Cause

Residential Admission -- Custody Holder Information
Custody Holder (if joint, check ALL that apply): Current Facility Biological Parents Adoptive Parents Non-Relative Biological Relative Step Parent DFCS DYS Commitment Other:
If DHR - Please Complete the Following:
Name of Agency Telephone
Address: Street City State Zip
Date Custody Granted Date Custody Terminates
Contact Person: Name Tel. # Emerg. #
Back-Up Contact Person: Name Tel. # Emerg. #

Residential Admission -- Admission and Discharge Information
The Child is Currently Living in (check one): Biological Parent's Home Relative's Home Foster Home Adoptive Home Group Home Residential Child Care RYDC YDC Emergency Shelter Intermediate Care Intensive Care Phsychiatric Hospital M.R. Institution Detox/Drug Treatment Other Alternative
Planned Placement upon Discharge from this Facility (check one): Biological/Adoptive Parents Independent Living Semi-Independent Living Other Relative Foster Home Group Home State M.R. Institution Other Child Care Institution

Residential Admission -- Educational Information
Present School: Current Grade:
Is this School (check one): Public Day School Private Day School Phsycho-ed Center Vocational School Remedial Tutorial Program Residential Institution Other (please explain):

Residential Admission -- Other Assessments
Juvenile Court Involvement:
Has child been found guilty of status offenses? Yes No Has child been found guilty of delinquent acts? Yes No Has child been placed on probation? Yes No Has child been committed to DYS? Yes No
If Yes to Any Question Above: Name of Court County Probation Officer Telephone
Mental Health History:
Has child ever received in-patient mental health service? Yes No Has child ever received out-patient mental health service? Yes No Has child ever received drug treatment? Yes No Did the child's family participate in the treatment? Yes No Has child ever received community mental retardation services? Yes No

Residential Admission -- Medical and Insurance Information
Insurance Policy Number Medicaid Number
Insurance Company Policy Holder
Contact Person Telephone
Does child take prescibed phsychotropic medications? Yes No If Yes, what and why? Does child regularly take other prescibed medications? Yes No If Yes, what and why? Does child have any known allergies? Yes No If Yes, what?