Admissions Inquiry Form

Referral Source Name *

First Name

Last Name

Phone Number *

(###)

###

####

Program(s) *

Please check the box of the program(s) for which you are seeking admission.

Residential

Day Treatment

Intensive In-Home

Discovery Home

Client's Legal Name *

Please do not include nicknames or aliases in this field.

First Name

Last Name

Client's Date of Birth *

MM

DD

YYYY

Legal Guardian *

First Name

Last Name

Phone Number *

Please add Legal Guardian's phone number.

(###)

###

####

Address *

Please add Legal Guardian's address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Current Behavioral Concerns *

Please check all behavioral concerns that apply to the client.

Suicidal Ideation

Homicidal Ideation

Assaultive Behaviors

Psychotic Symptoms

Perpetration

Suicide Attempt

Gang Involvement

Fire Setting

Self Harm

AWOL/Runaway Behaviors

Substance Use/Abuse

Impulse Control & Compulsions

Sexualized Behaviors

None

Trauma *

Please check all trauma areas that apply to the client.

Physical Abuse

Physical Neglect

Parental Substance Use/Abuse

Sexual Abuse

Emotional Neglect

Parental Mental Illness

Bullying

Emotional Abuse

Domestic Violence

Parental Loss

Grief/Loss

None

Who Holds Educational Rights? *

First Name

Last Name

Treatment Funding / Additional Funding Info *

Must select one or more.

Medicaid

CHP+

School District

County DHS

CHRP

CYMHTA