Admissions Application

Point of Contact Info

Referrer's Name

Demographics

Emergency Contact Information

Student Bio and Profile

Please provide a complete history of the applicant using the following outline. Be sure to include any and all major events in her life, from forward. Example: divorce, death of an immediate family member, molestation, surgeries or illnesses. Describe her academic history, including any special placements or learning disabilities. This information will prepare our staff to work most effectively with your teenager.

Home Life - Parent/Sibling Relationships

Schools

Behavior

To the best of your knowledge which of the following has the applicant used? Please check or describe below all that apply:

AlcoholCocaineFreonBarbituratesHallucinogenicOpiumMethamphetaminesGlueMushroomsHeroinMarijuanaCrack

Please check all that apply on the following questions:

The applicant has had severe family conflicts with:

MotherFatherStepparent(s)

The applicant has exhibited self-destructive behaviors:

Suicide attemptsCuttingOther (explain below)

Does the applicant have depression?

None ApparentMajorMild

Is the applicant attention deficit?

None ApparentInattentiveHyperImpulsiveMedicated for ADD/ADHD

Does the applicant exhibit aggressive behaviors?

Bullies, threatens, intimidatesPhysical violence, destruction of property

Family History

Siblings:

Parents/Guardians:

Who has legal custody?

Father:

Mother:

Parents' Marital Status:

MarriedDivorcedSeparatedLiving TogetherRemarried

When did the applicant last live with you?

To the best of your knowledge, what is the applicant's sexual lifestyle?

HeterosexualHomosexualBi-sexualPornographyChild PornographyIncest

Has she previously been enrolled in a board or military school? (If yes, please send a reference from the school)

NoYes

Legal History

Law Enforcement

If the applicant is currently on probation