Application Form

E-mail Address: *
Childs Full Name
Date of Birth
Place of Birth
Grade
Age
Race
Hair Color
Eye Color
Height
Weight
Social Security No.
Country
Primary Language
Religious Preference
Current Location of Child
Legal Guardian
Your Relationship to the child
Please list all contact numbers
Address
Please list all allergies, disabilities, diseases or medications
Reason Seeking Placement
Has child been placed away from home before? If yes, explain
What goals do you want your child to achieve through placement?
Describe childs behaviors including both appropriate and inappropriate behaviors
Does child have a history of substance abuse? If yes, explain
Does child have a history of being abused? (Physical, sexual, emotion, or neglect)
Does child have a history of abusive behaviors? If yes, explain
Does child have a history of involvement with the Juvenile Justice System? If yes, explain
Describe childs strengths (socailly, behaviroal, athletically, musically, etc.) Does child have a special talent of gift? Has child received special recognition in school or other areas?
Has child demonstrated any interest in violent popular culture? (I.e. horror movies, books, music with graphically violent or occult themes)
Does child identify with any partcular social sub-group (skater, punk, metal head, prep, gangs, etc?)
Talks about killing self
Earnestly attempted suicide
Damages or destorys own property
Damages or destroys property of others
Vandalizes
Set Fires
Runs away from home
Steals at 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Withdrawn, does not get involved with other children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
Describe childs adjustment in school. Has child ever been in In-School Suspension, SAC, expelled, or attended behavioral modification classes? If yes, explain:
Please list last grade completed. Does child have a history of truancy? Has child ever repeated a grade level?
Describe any problems that child has in school. (relating to teachers or school personnel, concentration, organizational skills, turning in homework, etc.)
Discuss childs current educational level. (Resource classes, grades, conduct, etc.)
Did child have any difficulties in achieving develpmental milestones such as learning to walk, talk or function properly? If yes, explain:
Briefly describe childs current level of functioning:
Describe childs past and current medical history. Has your child been on any long-term prescribed medications?
Is child accident prone or has child suffered any injuries to the head. (Fallen, knocked-out, car accidents, etc.)?
List the childs previous experiences with psychiatric counseling, evaluation, or hospitlizations. Did he benefit from it?
Does child have any special needs or require any special care?
Does child wear glasses, contact lens, hearing aid, braces, retainers or any other devices that will need a doctors services?
List all persons living with the child at this time, relationship and age:
Is child adopted? If yes, at what age? Does child know the biological parents?
Have the parents been separated or divorced during the childs life? How old was the child at the time?
Briefly describe childs living environlment for the first three years of life. (Stable, loving, chaotic, violent, etc):
Briefly describe childs relationship with family members:
Briefly describe childs relationship with other adults (grandparents, aunts, uncles, etc.)
Has there been a death of anyone close to the child, such as a father, mother, brother, sister, grandparent, friend? What was the cause of death?
Do any family members have emotional, physical or learning problems? If yes, explain:
Have there been any other significant incidents in the childs life that were difficult for the child and would help us understand the childs problems?
Suicide	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Violent towards family	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Drug Abuse	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Alcohol Abuse	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Sexual Abuse	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Sexual Misconduct	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Psychiatric Problems	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Chronic Poverty	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Criminal Behavior	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Jail or Prison	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Discipline Skills Lacking	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Isolation	Natural Father Natural Mother Siblings Step-Father Step-Mother Paternal Grandfather Paternal Grandmother Maternal Grandfather Maternal Grandmother
Please list all monthly incomes including Net Salary, Second Net Salary, Child support, S.S Benefits, Disability and any other form of income
Please list all monthly debts including Rent/House Payment, Monthly Utilities, Child Support, Credit Cards, etc.
Name of person completing application and relationship to child:


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