APPLICATION FOR ADMISSION

Fields marked by a + are required ( all others are optional )

YOUTH  INFORMATION

Application Date:
Program: 
+ First Name:
+ Last Name:
+ SSN:
+ Date of Birth:
+ Gender:
 Male Female
Race: (Choose One)
African American
 Hispanic
 Native American		 Asian
 Caucasian
 Other: (Specify)

REFERRAL  SOURCE  INFORMATION

County of Referral:
+ Referral Source Name:
+ Address Line 1:
Address Line 2:
+ City:
+ State:
+ Zip Code:
+ Contact Name:
+ Day Time Phone:
+ Referral Source Type: (Choose One)
Church
 Hospital
 Health Services
 Residential Treatment
 School
 Youth Organization
 Court/Youth Services
Family
 Psychiatrist
 Psychologist
 Social Serv./ M. H. Agency
 Social Worker (Pvt. Practice)
LEGAL  CUSTODIAN  AND  PRIMARY  CONTACT
+ Salutation:
+ Last Name:
+ First Name:
+ Spouse's Name:
+ Does youth live with this person: Yes No
+ Address Line 1:
Address Line 2:
+ City:
+ State:
+ Zip Code:
+ Home Phone:
Work Phone:
Other Phone:
Other Phone Type:
Beeper Cellular Fax    Friend Relative
+ Relationship to Youth: (Choose One)
Parent(s)
 Foster Parent
 Grandparent
 Stepparent
 Sibling
 Stepsibling
 Other Relative
 Guardian Ad Litem
 Legal Guardian
 Neighbor
 Social Service/Caseworker (Foster Care)
OTHER EMERGENCY CONTACT
Salutation:
Last Name:
First Name:
Spouse's Name:
Does youth live with this person: Yes No
Address Line 1:
Address Line 2:
City:
State:
Zip Code:
Home Phone:
Work Phone:
Other Phone:
Other Phone Type:
Beeper  Cellular Fax Friend Relative
Relationship to Youth: (Choose One)
Parent(s)
 Foster Parent
 Grandparent
 Stepparent
 Sibling
 Stepsibling
 Other Relative
 Guardian Ad Litem
 Legal Guardian
 Neighbor
 Social Service/Caseworker (Foster Care)

HEALTH  INSURANCE  INFORMATION

Health Insurance Co:
Policy No:
Group Insurance No:
Health Insurance Phone:
Employer:
Policy Holder:
Policy Holder SSN:

PHYSICAL  HEALTH  INFORMATION

+ Allergies:
+ Current Medication(s):
+ Medical Conditions/
Impairments:
NOTE: Additional information such as the child’s medical history, educational records and clinical information will be required to evaluate this application. Admissions representatives will assist you in compiling all information needed.