The Boyd School, Inc.
A Treatment Facility
P.O. Box 127
Green Pond, AL 35074
Date of Referral: ______________
APPLICATION FOR ADMISSION
PERSON MAKING REFERRAL: _________________________________CONTACT TELEPHONE #:_______________________
ADDRESS:__________________________________________________________________________________________________
SUPERVISOR:_______________________________________________ CONTACT TELEPHONE #:________________________
CHILD: __________________________________________________ DOB:__________ AGE:________ SSN:___________________
DHR CASE#:_______________ CATEGORY:_________________ MEDICAID/INSURANCE #:____________________________
RELIGION:__________________RACE:_____ HEIGHT:______ WEIGHT:______ HAIR COLOR:_______EYE COLOR:_________
REASON FOR REFERRAL:_____________________________________________________________________________________
____________________________________________________________________________________________________________
CHILD’S PRESENT LOCATION:_____________________________________DURATION OF RESIDENCE:__________________
LEGAL STATUS: DEPENDENT ____________ CHINS ____________ DELINQUENT ___________ OTHER _______________
LEGAL CUSTODIAN: _______________________________________________________ ADDRESS: ________________________
____________________________________________________________________________________________________________
DOES CHILD HAVE VISITING RESOURCE? YES _____ NO _____ NAME & ADDRESS:__________________________________
____________________________________________________________________________________________________________
PREVIOUS PLACEMENTS:
WITH WHOM
DURATION
REASON FOR MOVE
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
MEDICAL HISTORY:
DATE OF LAST EPSDT/PHYSICAL: ______________________ ATTENDING PHYSICIAN: _______________________________
DIAGNOSTIC IMPRESSIONS: __________________________________________________________________________________
___________________________________________________________________________________________________________
CURRENT MEDICATIONS: ___________________________________________________________________________________
CHECK IF CHILD HAS HAD:
______ MEASLES ______MUMPS
______CHICKEN POX ______ SCARLET FEVER
______ WHOOPIING COUGH
______ TB SKIN TEST DATE: _______________ WHERE: ____________________________ RESULTS: ____________________
______ SICLE CELL ANEMIA TEST DATE: _________ WHERE: _______________________ RESULTS: ____________________
HOSPITALIZATIONS:
NAME OF HOSPITAL
DATE ADMITTED
DOCTOR
REASON FOR ADMISSION
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
AGENCY REFERRAL/APPLICATION FOR ADMISSION 2005
DESCRIBE ANY PHYSICAL, MEDICAL, DEVELOPMENTAL, OR PSYCHOLOGICAL PROBLEMS THAT WILL REQUIRE
SPECIAL ATTENTION IN CARING FOR THIS CHILD:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
CHECK IF CHILD HAS EVER HAD A PROBLEM WITH:
___ SEIZURES
___ HEARING
___ VISION
___ MOUTH
___ LEARNING
___ SWALLOWING
___ HEAD
___ HEART
___LUNGS
___URINARY
___TALKING
___ BREATHING
___ FEET
___ BACK
___ SKIN
___RECTUM
___ WALKING
___ CHEWING
___HANDS
___ABDOMEN
___NOSE
___GENITALIA
___CRAWLING
___ NECK
___ ARMS
___ LEGS
___ THROAT
___ALLERGIES
___SITTING
___ OTHER
IF CHECKED, PLEASE EXPLAIN: _______________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
DATE OF LAST PSYCHOLOGICAL EVALUATION/PSYCHOLOGICAL TESTING: ______________________________________
EVALUATIONS PERFORMED BY: ________________________________________ CONTACT #: _________________________
VERBAL IQ SCORE: _______________PERFORMANCE IQ SCORE: _______________FULL SCALE IQ: _____________________
EDUCATION:
CURRENT/LAST SCHOOL ATTENDED: __________________________________________________ GRADE: ______________
ADDRESS: ____________________________________________________________________________ PHONE: ______________
IS CHILD RECEIVING SPECIAL EDUCATION SERVICES? YES
NO
IF YES, _______ LD
_______ ED
_______EMR
CHECK APPLICABLE SCHOOL PROBLEMS:
___ PEER RELATIONSHIPS
___ AGGRESSION TOWARD PEERS
___ AGGRESSION TOWARD PROPERTY
___ TRUANT
___ UNDERACHIEVER
___ UNDERSOCIALIZED
___THEFT
___PROBLEMS W/ AUTHORITY FIGURES ___ OTHER
PARENT/FAMILY INFORMATION:
PARENT’S MARITAL STATUS: ___ MARRIED ___SEPARATED ___DIVORCED ___ WIDOWED ___ NEVER MARRIED
FATHER: DOB: ________________ SSN:_______________________________
___ LIVING
___ DECEASED
IF DECEASED, DATE AND CAUSE OF DEATH: _________________________________________________________________
NAME: __________________________________ ADDRESS:________________________________________________________
PHONE: _________________________________ PLACE OF EMPLOYMENT: _________________________________________
PRESENT SPOUSE (COHABITATING?): ________________________________________________________________________
GENERAL HEALTH: ______________________ DATE OF LAST CONTACT W/ AGENCY: _____________________________
MOTHER: DOB: ________________ SSN:_______________________________
___ LIVING
___ DECEASED
IF DECEASED, DATE AND CAUSE OF DEATH: _________________________________________________________________
NAME: __________________________________ ADDRESS:________________________________________________________
PHONE: _________________________________ PLACE OF EMPLOYMENT: _________________________________________
PRESENT SPOUSE (COHABITATING?): ________________________________________________________________________
GENERAL HEALTH: ______________________ DATE OF LAST CONTACT W/ AGENCY: _____________________________
AGENCY REFERRAL/APPLICATION FOR ADMISSION 2005
SIBLINGS:
NAME
SEX
AGE
ADDRESS AND PHONE
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
PLEASE ATTACH IN NARRATIVE FORM A SOCIAL SUMMARY THAT COVERS AT LEAST THE FOLLOWING:
1.
2.
3.
4.
5.
6.
7.
PRENATAL CARE (LENGTH OF PREGNANCY, DURATION OF LABOR, COMPLICATIONS, ETC.),
CURRENT LIVING SITUATION AND WHY CHANGE IN PLACEMENT IS SOUGHT,
PLACEMENT HISTORY,
CHILD’S ACTING OUT BEHAVIORS, BE VERY SPECIFIC,
CHILD’S STRENGTH AND NEEDS,
CHILD’S INTERESTS, TALENTS, SPECIAL SKILLS,
PARENTAL HISTORY AND FAMILY DYNAMICS, INCLUDE PARENTAL STRENGTHS AND NEEDS,
SIGNIFICANT OTHERS AND THEIR ROLES, MENTAL ILLNESSES, PHYSICAL DISABILITIES,
INCARCERATIONS, SUBSTANCE ABUSE, ETC.,
8. REUNIFICATION ATTEMPTS WITH PARENTS/RELATIVES,
9. RESTRICTIONS ON VISITATION, TELEPHONE AND MAIL ACCESS,
10. CASE PLAN AND TIME FRAMES.
OTHER:
ATTACH RECENT COPY OF MEDICAL, PSYCHOLOGICAL, SOCIAL SECURITY CARD, MEDICAID CARD, CERTIFICATE OF
IMMUNIZATION, BIRTH CERTIFICATE, CURRENT IEP AND ISP, AND EDUCATIONAL RECORDS.
AGENCY REFERRAL/APPLICATION FOR ADMISSION 2005