Admissions Inquiry Form

Referral Source Name
Phone Number
Program(s)
Please check the box of the program(s) for which you are seeking admission.
Client's Legal Name
Please do not include nicknames or aliases in this field.
Client's Date of Birth
Please specify gender if "Other"
Legal Guardian
Please include Legal Guardian's relationship to the client.
Phone Number
Please add Legal Guardian's phone number.
Address
Please add Legal Guardian's address.
Please provide the language of the client's primary caregiver.
Current Behavioral Concerns
Please check all behavioral concerns that apply to the client.
Trauma
Please check all trauma areas that apply to the client.
Please include provider names and dates of placement.
Please provide provider name and start date of placement.
Please include a brief description of why you are seeking services for this client, including information on problematic behaviors, aggression, elopement, etc.
Please speak to the client's family dynamics and engagement of viable family members.
Please include charges, drugs of choice, and gang affiliation if applicable.
Please include client's most recent DSM diagnosis(es).
Please include notable medical concerns and allergies.
Please add the name of the last school the client attended.
Please add the current grade or the last grade the client completed.
Who Holds Educational Rights?
Please include in-school suspensions, detention, office referrals, etc.
Treatment Funding
Must select one or more.
Please include Medicaid number, name of payer agency, Medicaid RAE, and/or individual responsible for funding.
Please provide names, phone numbers, and e-mail addresses for other stakeholders (current caregiver, caseworker, probation officer, GAL, and other professionals).