Basic care home for at-risk boys

Sufficient factual information must be disclosed to the Casework Manager to accurately evaluate the child's needs and the ability of this facility to meet those needs.
Boys' Haven is a basic care residential facility, equipped to serve children who meet the following criteria.

In order to qualify for admittance into Boys' Haven, the child must:
1. Be at least 6 years of age;
2. Be able to physically participate in a very demanding and active program;
3. Be free from contagious or infectious disease, and cannot require a special diet;
4. Not be physically or emotionally dependent on drugs or alcohol;
5. Be able to attend and be enrolled in public school;
6. Not be severely mentally impaired;
7. Not be an endangerment to himself or others (i.e. he cannot be suicidal, homicidal, set fires, hurt animals);
8. Be able to function in an environment where compliance to the rules is mandatory without the use of physical force;
9. Be able to receive support in developing and maintaining social skills appropriate to his age and development;
10. Be able to participate in age and developmentally appropriate activities to promote his well being;
11. Not be significantly organically impaired;
12. Meet basic, moderate, or specialized level of care criteria.

The individual seeking placement for the child must have legal guardianship or authority of him. Documentation of custody is required prior to placement.
The party first in legal authority over the child shall, by notarized contract, place the child in the care, custody, and control of Boys' Haven for a minimum of one year. This contract does not terminate the legal guardianship of the party.
The application must be filled out completely and to the best of your knowledge. Once the application has been received, allow one week for the review process to take place.
Availability of placement is not guaranteed when an application is received.
If all available room is currently taken, your child will be placed on a waiting list, based on his need for care. The waiting list is not based on a first come, first serve basis. Each application is reviewed carefully and placement is determined by which applicant needs the most immediate care.
Once the application has been reviewed and it is determined that the child meets placement criteria, he will be called in for a pre-placement visit which consists of a 3 day visit during which the child will stay at Boys' Haven. During this time, he will be evaluated by staff to determine placement eligibility. The cost of the pre-placement visit is based on a sliding fee scale determined by the information on your pay stubs and tax return. The child must bring proof of a recent TB skin test to the pre-placement meeting.
Once the pre-placement visit concludes, a Boys' Haven representative will contact the guardian to discuss enrollment eligibility. If it is determined that the child should return to placement, and both parties are in agreement, a date for placement will be set as soon as possible. Prior to returning for placement the child must receive an updated physical and dental exam and receive any necessary immunizations.
The guardian and a Boys' Haven representative will discuss the amount to be paid for Program Service Fees monthly and the method of payment prior to placement. This amount will be recorded on a notarized form on which the legal guardian will sign verifying the amount and method of payment at the time of placement. Program Service Fees are based on a sliding fee scale.
All information obtained from the application and additional paperwork is confidential and will only be reviewed by Boys' Haven staff. The legal guardian reserves the right to withdraw the child's application at any time.

Child's Full Name:
Date of Birth:
Place of Birth:
Grade:
Age:
Race:
Hair Color:
Eye Color:
Height:
Weight:
Social Security #
Citizenship
Citizenship, if other, please explain:
Primary Language:
Religious Preference:
Current Location of the Child:
Legal Guardian:
Your relationship to the child:
Home Phone:
Work Phone:
Home Address:
City, State, & Zip
Referring Agency (if applicable):
Contact Person:
Phone:
Email Address:
Medical Conditions:
Allergies:
Disabilities:
Diseases:
Medications:
Past Medications and Dates Taken:
Previous Surgery:
Distinguishing Marks:
Family Doctor:
Other Doctor 1:
Phone:
Other Doctor 2:
Phone:
Other Doctor 3:
Phone:
Please complete each question to the best of your ability:
Reasons seeking placement:
Has child been placed away from home before?
If yes, please explain:
Number of out of home placements:
Date of discharge from most recent out of home placement:
Reason for discharge:
Goals you want your child to achieve through placement:
Your expectations of placement for your child:
How long do you expect your child to remain in placement, if they stay after their one year minimum stay? And what do you expect your involvement will be during their placement here?
Describe the child's behavior (both appropriate and inappropriate):
Does the child have a history of substance abuse?
If yes, please explain:
Does the child have a history of being abused?	Physical Sexual Emotional Neglect
Please explain:
Does the child have a history of abusive behaviors?
If yes, please explain:
Has the child ever been accused of inappropriate sexual behaviors?
If yes, please explain:
Does the child have a history of involvement with the Juvenile Justice System?
If yes, number of referrals to juvenile authorities:
Is child currently on probation
Date probation started:
List offenses:
Describe child's strengths (socially, behaviorally, athletically, musically, etc.) Does the child have a special gift or talent? Has the child received special recognition in school or other areas?
Has the child demonstrated any interest in violent popular culture? (i.e. horror movies, books, music wiht graphically violent or occult themes)
Does the child identify with any particular social sub-group: skater, punk, metal head, prep, gangs, etc.?
Does child have difficulty getting along with children his own age?
Check the appropriate slot describing the frequency of the behavior within the last 6 months.
Talks about killing self
Earnestly attempts suicide
Hurts animals
Damages or destroys own property
Damages or destroys the property of others
Vandalizes
Sets fires
Runs away from home
Steals at home
Steals outside of home
Wets self during the day
Wets the bed
Has bowel movements outside the toilet
Does not appear to feel guilty after misbehaving
Lies and/or cheats
Withdrawn, does not get involved with other children
Prefers playing with older children
Has trouble sleeping
Demands attention
Gets into fights
Associates with children who get into trouble
Swears, uses obscene language
Has temper tantrums, is volatile
Impulsive, acts without thinking
Education
Describe your child's adjustment to school. Has the child ever been in In-School suspension, SAC, expelled, or attended behavorial modification classes? If yes, please explain:
Last grade completed:
Does the child have a history of truancy?
Has the child ever repeated a grade level?
If yes, which grade level. Please explain:
Describe any problems that the child has in school. (i.e. relating to teacher's or school personnel, concentration, organizational skills, turning in homework, etc.):
Discuss the child's current educational level. (i.e. resource classes, grades, conduct, etc.):
Developmental and Medical History
Explain the child's birth history:
Birth weight:
Length:
Hospital:
Problems during pregnancy/labor/delivery:
Developmental:
If delayed, please explain:
Accidents/Illness:
Surgery/Broken bones:
Hospital Stays:
Did child have any difficulties in achieving developmental skills, such as learning to walk, talk, or function properly?
If yes, please explain:
Describe the child's current level of functioning:
Has your child been on any long term prescribed medications?
Is the child accident prone or has the child suffered any injuries to the head? (i.e. fallen, unconscious, car accidents, etc.):
List the child's previous experiences with psychiatric counseling, evaluations, or hospitalizations. Did he benefit from them?
Does your child have any special needs or require special care? Please explain:
Does the child wear glasses, contact lenses, hearing aids, braces, retainers, or any other devices that will need doctor's services?
Family History
Father NAME, AGE, EDUCATION, & CURRENT JOB:
Mother NAME, AGE, EDUCATION, & CURRENT JOB:
Siblings:
Other persons living with the child at this time (Name, relationship, and age)
Child lives with:
Living arrangements
Number of bedrooms:
Pets:
School presently attending:
Is the child adopted? If yes, at what age? Does the child know the biological parents?
Have the parents been separated or divorced during the child's life? How old was the child at the time?
List any remarriages of either parent and dates:
Briefly describe child's living environment for the first three years of their life: (stable, loving, chaotic, violent, etc.):
Briefly describe the child's relationship with family members (parents, grandparents, siblings, etc.):
Briefly describe the child's relationship with other significant adults:
Has there been a death of anyone close to the child, such as a father, mother, brother, sister, grandparent, or friend? What was the cause of this death? How did it affect the child?
Do any family members have emotional, physical, or learning problems? If yes, please explain:
Have there been any other significant incidents in this child's life that were difficult for the child and would help us understand the child's problems? (i.e. multiple moves, physical/emotional abuse, parental conflics, etc.):
Please estimate hours family is away from home:
Father regularly away from home: (hours)
Daily:
Weekends:
Mother regularly away from home: (hours)
Daily:
Weekends:
Youth regularly away from home: (hours)
Daily:
Weekends:
FAMILY CHECKLIST: Please check individual family members who have or have had any of the following:
Violent towards family	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Suicide	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Drug Abuse	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Alcohol Abuse	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Sexual Abuse	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Sexual Misconduct	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Psychiatric Problems	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Chronic Poverty	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Criminal Behavior	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Jail or Prison	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Discipline skill lacking	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother
Isolation	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfatehr Paternal Grandmother Maternal Grandfather Maternal Grandmother

"Building Brighter Tomorrows for the Boys of Today"

ADMISSIONS

Admittance Requirements and Application Procedure:

ADMISSION FORM