Questionnaire

Your Name (required):

Your Email (required):

Your Relationship to Child (required):

Your Telephone(required):

Your Address:
Address Line 1:
Address Line 2 (If Applicable):
City: State: Zip:

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CHILD'S INFORMATION:

Child's Name:
AKA (Nickname):
Medicaid Number:
Date of Birth: Age: Gender: Height: Weight: lbs.
Religious Affiliation: Other Religious Affiliation:
Place of Birth: County of Legal Custody:
Legal Custodian: Relationship to Child:
Address Line 1:
Address Line 2 (If Applicable):
City: State: Zip:

Distinguishing features (i.e., scars, tattoos, birthmarks, etc.):

Hobbies:

Child's Strengths:
 Good Socialization Skills
 Appropriate Coping Skills
 Appropriate Reading Level
 Strong Family Base
 Good Verbal Skills
 On Grade-Level
 Average/Above IQ
 Good Personal Hygiene
 Other:

Reason for Applying:

Number of previous Placements:

List Schools Attended and/or Special Classes/Training:

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CURRENT BEHAVIORAL PROBLEMS/WEAKNESSES (Check all that apply).
 Low Self-esteem
 Poor Social Skills
 Developmentally Delayed
 Below Grade Level
 Aggressive (Verbally)
 Anxiety
 Abandonment Issues
 Depression
 Poor Personal Hygiene
 Sibling Related Difficulty
 Antisocial Behavior
 Difficulty with Authority
 Parental Neglect Issues
 Poor Reality Orientation
 Functionally Illiterate
 Impulsive
 Poor Coping Skills
 Running Away
 Unruly/Ungovernable
 Self-Destructive Behavior
 Physical Disability (specify):
 Hyperactive
 Oppositional/Defiant
 Destroys Property
 Arson
 Aggressive (Physical)
 Truancy
 Loss/Grief Difficulties
 Steals
 Other (specify):

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MEDICATIONS
List all current medications, dosages, and instructions:

List any known, pre-existing medical conditions/physical disabilities:

MEDICAL CONDITIONS

 Asthma
 Fainting
 Anorexia
 HIV/AIDS
 Headaches
 Convulsions
 Enuresis
 Sinusitis
 Diabetes
 Hay Fever
 Lice
  Seizures
 Hepatitis
 Eczema
 Bulimia
  Other (please specify):

Date of Last Physical Exam: Dental Exam: Eye Exam:
Dental Appliances?  Yes No
Contacts/Glasses?  Yes No

Allergies:
Special Dietary Needs:

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FAMILY INFORMATION

Biological Mother’s Name:
Address Line 1:
Address Line 2 (If Applicable):
City: State: Zip:
Home Phone: Cell Phone: Race:
Educational Level (if known): Criminal Record?  Yes No

Biological Father's Name:
Address Line 1:
Address Line 2 (If Applicable):
City: State: Zip:
Home Phone: Cell Phone: Race:
Educational Level (if known): Criminal Record?  Yes No

Are the Parents:
 Married Separated Divorced
 Deceased? Which One?  Other?
Have Parental Rights Been Terminated?  No Yes (if yes, date):

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FAMILY CONTACT
Significant Family Member(s) and Relationship to Child:

Address Line 1:
Address Line 2 (If Applicable):
City: State: Zip:
Home Phone: Cell Phone:

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OTHER APPROVED CONTACTS

Name and Relationship to Child:

Address Line 1:
Address Line 2 (If Applicable):
City: State: Zip:
Home Phone: Cell Phone:
Type of Contact with Child (phone, letters, face-to-face, etc.):

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SCHOOL INFORMATION

Home School District:
Is child currently classified Special Education?  Yes No Unknown
Does child have current IEP?  Yes No Unknown (If yes, date):
Does child have section 504 Plan?  Yes No Unknown (If yes, date):
Does child have history of truancy?  Yes No Unknown
Has child ever been suspended?  Yes No Unknown
Is child currently under recommendation for expulsion?  Yes No Unknown
(If yes, enter reason):
Is the child functioning at grade level?  Yes No (If below, please indicate grade level):

IQ/ACHIEVEMENT/ADAPTIVE TESTING
Name of Test: Date: Given By:
Scores and Ranges, e.g., Low. Average, etc.:

Is the IQ score considered valid by the examiner?  Yes No
If no, explain:

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Goals
Goals You Would Like to See From Academy:

Family's Goals for Academy:

Educational Goals or Desires from Academy:

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