CARPENTER PLACE
APPLICATION FOR ADMISSION
(When information is unknown or not available, please indicate)
I. CHILD (Identifying Information) ** include copy of Birth Certificate
A. Name_____________________________ Name Called _____________________
Social Security Number ______________________________________________
Age __________ Birth Date __________ Birthplace ________________________
Sex ________________ Height ________________ Weight _________________
Color of Hair _____________ Eyes _____________ Complexion ______________
National Origin ____________ Race ___________ Religion __________________
Physical Handicaps _________________________ General Health ___________
- With Whom Living ___________________________________________________
Name ______________________________ Relationship ____________________
How Long ________ Address __________________________________________
Phone ____________________________
- C. Legal Guardian ***INCLUDE COPY OF CUSTODY PAPERS
(Person having legal custody of Child)
Name ______________________________ Relationship ____________________
Address ___________________________________________________________
Phone ____________________________
- What type and how much monthly assistance does the child receive? (SSI, Child Support, etc.) ______________________________________________________
________________________________________________ $________________
Whom to Notify to Come for Child ______________________________________
Address _____________________________________Phone ________________
- Development History
- Pregnancy: Normal _____Yes____ No If no, describe complications
____________________________________________________________
Term of Pregnancy ____________________________________________
- Delivery: Anesthesia _________________ Hours of hard labor __________
Baby Weight: ____________ lbs. ____________ oz.
Incubator: _____Yes _____ No If yes, please comment: _____________
____________________________________________________________
Post Partum Depression: _____ Yes _____ No Other Complications?
____________________________________________________________
3. Infancy: Age Weaned ___________ Colic? _____ Yes _____ No
Age of First Words _____________ Complete Sentences ______________
Age Toilet Trained ______________ Daytime ______________Nighttime
- Siblings
Name Age School/Grade Location
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
- NATURAL PARENTS
FATHER
- Name _________________________________________ Age _______________
Birthplace _______________________________ Date of Birth _______________
Address ____________________________________Telephone ______________
Religious Preference __________________ Place of Worship________________
Education ________________________ Health ___________________________
Type of Relationship, if any, with the child? _______________________________
Cause of Death, if Deceased __________________________________________
- Occupation _______________________ Social Security No _________________
Where Employed ___________________________________________________
(Firm’s Name)
Address _________________________________ Phone ___________________
How Long? ____________________ Present Annual Salary $________________
- Habits, Character, Personality Traits ____________________________________
__________________________________________________________________
Alcohol Abuse? __________ Mental Illness? __________Ever Treated for Mental
Illness? ___________________________________________________________
- Service Record
Branch _________________________________ Serial No __________________
Entered __________________________ Discharged _______________________
Type of Discharge ___________________________________________________
E. Name of Spouse Date Married Date Ended Reason Ended
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________
NOTE: IF THERE IS A STEPFATHER OR ADOPTIVE FATHER, PLEASE SUBMIT THE ABOVE INFORMATION ON A SEPARATE SHEET, GIVE DATES OF MARRIAGE AND ADOPTION.
MOTHER
- Name _________________________________________ Age _______________
Birthplace ________________________________Date of Birth _______________
Address ____________________________________Telephone______________
Religious Preference __________________ Place of Worship ________________
Education ________________________ Health ___________________________
Type of Relationship, if any, with the child? _______________________________
Cause of Death, if Deceased __________________________________________
- Occupation _______________________ Social Security No _________________
Where Employed ___________________________________________________
(Firm’s Name)
Address _________________________________ Phone ___________________
How Long? ____________________ Present Annual Salary $________________
- Habits, Character, Personality Traits ____________________________________
__________________________________________________________________
Alcohol Abuse? __________ Mental Illness? __________Ever Treated for Mental
Illness? ___________________________________________________________
D. Service Record
Branch _________________________________ Serial No __________________
Entered __________________________ Discharged _______________________
Type of Discharge ___________________________________________________
E. Name of Spouse Date Married Date Ended Reason Ended
1. ________________________________________________________________
2. ________________________________________________________________
3. ________________________________________________________________
NOTE: IF THERE IS A STEPMOTHER OR ADOPTIVE MOTHER, PLEASE SUBMIT THE ABOVE INFORMATION ON A SEPARATE SHEET, GIVE DATES OF MARRIAGE AND ADOPTION.
- VISITING PERSONS
List ALL relatives and/or persons who might visit or telephone the child, indicating under “Effect of Visit” whether such a visit might be PROFITABLE, USELESS or DISTURBING to the child.
NAME RELATIONSHIP EFFECT OF VISIT
_________________________ _____________________ ________________________
_________________________ _____________________ ________________________
_________________________ _____________________ ________________________
_________________________ _____________________ ________________________
_________________________ _____________________ ________________________
_________________________ _____________________ ________________________
_________________________ _____________________ ________________________
_________________________ _____________________ ________________________
- SCHOOL INFORMATION
A. Schools Attended (List last 4 starting with present) Date Attended Grade
______________________________________ _______________ __________
______________________________________ _______________ __________
______________________________________ _______________ __________
______________________________________ _______________ __________
- Is child in Resource or Special Education? ________________________________
- Age at which child began first grade? __________ How did child profit from school experience? _______________________________________________________
__________________________________________________________________
__________________________________________________________________
- Is child considered to be a school discipline problem? ____________Does the child like school?____________________________________________________
__________________________________________________________________
- If not now in school, reason for discontinuing. _____________________________
__________________________________________________________________
V. PERSONAL DATA
- MEDICAL **Include a copy of insurance card (front/Back)
Insurance Company ________________________ Policy # __________________
Child’s Physician
Name ____________________________________________________________
Address ___________________________________________________________
Phone ____________________________
What medications is the child presently taking?
Name What For
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
Surgery:
Date Place / Hospital Type Outcome
_______ ___________________________ ___________ _______________
_______ ___________________________ ___________ _______________
_______ ___________________________ ___________ _______________
Significantly High Fever? __________ Nature _____________________________
Age when occurred _______ Duration of Fever ____________________________
If more than one, how many? __________________________________________
Shots / Immunizations ***Include copies of Immunization records
_________________________________________
SIGNATURE
_________________________________________
Print Name
_________________________________________
Relationship to Child
_________________________________________
DATE
Admission Assessment
Presenting Concern:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Suicidal Ideations/thoughts: Y_______ N_________
Attempts: Y_______ N_________
….if yes, # of attempts and dates _____________________________________________
________________________________________________________________________
Plan: Y_______ N_________
…if yes, what is the plan: ________________________________________________
________________________________________________________________________
Homicidal thoughts: Y________ N_________
….if yes, to whom and plan: ________________________________________________
________________________________________________________________________
Aggressive behavior: Y_________ N_________
….if yes, to whom and type of behaviors_______________________________________
________________________________________________________________________
Self mutilation/ harmful to self Y_______ N_______
….if yes, how____________________________________________________________
________________________________________________________________________
Property Damage: Y_________ N_________
….if yes, what type________________________________________________________
Has the person been diagnosed: Y_______ N _______
….if yes, what is the current diagnosis?_______________________________________
Losses: Y_______ N_______
….if yes, what kind_______________________________________________________
Recent Trauma: Y_______ N_______
….if yes, what kind_______________________________________________________
_______________________________________________________________________
_______________________________________________________________________
History of rape or sexual abuse Y_______ N_______
….if yes, please explain____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
History of physical abuse Y_______ N_______
….if yes, please explain____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
History of emotional abuse Y_______ N_______
….if yes, please explain____________________________________________________
_______________________________________________________________________
_______________________________________________________________________
History of runaway behavior Y_______ N_______
….if yes, number of times and duration, how did child return____________________________________________________________________________________________
Behavioral Problems in Judgment
Disorganized Behavior Y_______ N_______
Irritable or Angry Y_______ N_______
Impaired Judgment Y_______ N_______
Inattention to details Y_______ N_______
Short attention span Y_______ N_______
Does not listen Y_______ N_______
Does not follow through w/instruction Y_______ N_______
Trouble organizing tasks Y_______ N_______
Easily distracted Y_______ N_______
Interrupts or intrudes Y_______ N_______
Steals Y_______ N_______
Violates rules Y_______ N_______
Loss of temper Y_______ N_______
Refuses to comply with expectations Y_______ N_______
Easily annoyed by others Y_______ N_______
Sexually active Y_______ N_______
Ever been pregnant Y_______ N_______
Ever used any form of birth control Y_______ N_______
Ever had an abortion Y_______ N_______
Substance Abuse/ cigarettes Y_______ N_______
….if yes, what substances used, amounts and duration_________________________
_______________________________________________________________________
Behavior Problems in Movement
Psychomotor agitation Y_______ N_______
Disorganized or catatonic behaviors Y_______ N_______
Repetitive Behaviors Y_______ N_______
Restlessness or on edge Y_______ N_______
Fidgets, nervous tics Y_______ N_______
Socialization
Withdrawn from family Y_______ N_______
Withdrawn from friends Y_______ N_______
Isolative Y_______ N_______
Quiet Y_______ N_______
Concentration Problems
Decreased concentration Y_______ N_______
Does not respond when first spoken to Y_______ N_______
Decreased concentration at school Y______ N_______
Mood Problems
Mood swings Y_______ N_______
Flat affect (neither smiles nor frowns) Y_______ N_______
Depressed Y_______ N_______
Does not care attitude Y_______ N_______
Episodes of crying Y_______ N_______
Episodes of anger Y_______ N_______
Anxious Y_______ N_______
Physiologic Symptoms
Insomnia decreased or increase sleep Y_______ N_______
Restless sleep Y_______ N_______
Nausea or vomiting Y_______ N_______
Shortness of breath Y_______ N_______
Chest discomfort Y_______ N_______
Lightheaded Y_______ N_______
Increase weight Y_______ N_______
Decrease in weight Y_______ N_______
Eating disorder Y_______ N_______
….if yes, please explain____________________________________________________
________________________________________________________________________
________________________________________________________________________
Thought Problems
Hallucinations Y_______ N_______
Fear of losing control Y_______ N_______
Delusions Y_______ N_______
Paranoia Y_______ N_______
School
Currently in school Y_______ N_______
….if no, what is the status___________________________________________________
________________________________________________________________________
Current grades :___________________________________________________________
Legal
Are there any current or previous legal problems or charges? Y_______N_______
….if yes, explain in detail___________________________________________________
________________________________________________________________________
________________________________________________________________________
Is child in treatment or counseling at this time? Y_______ N_______
….if yes, list name, address, duration and reason_________________________________
________________________________________________________________________
________________________________________________________________________
Psychological testing Y_______ N_______
….if yes, when and diagnosis and by whom____________________________________
_______________________________________________________________________
Previous psychiatric hospitalization? Y_______ N_______
….if yes, dates, places and duration________________________________________
________________________________________________________________________
What are the long term goals and expectations of placement for the child to return home?
________________________________________________________________________
________________________________________________________________________
Are both parents in agreement about placement? Y_______ N_______
….if no, please explain_____________________________________________________
________________________________________________________________________
Provide at least a paragraph or two explaining how the child’s problems began and when.
Include situations that may involve family, community, school, etc. Include any and all factors you feel could have contributed he child’s problem areas such as abuse, divorce, death of a parent, influence by peers, etc.
What do you see as strengths/ weaknesses of this child?
(use back page if necessary)
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Admission Check List
These items are needed the day you come to admit.
- Medical Record Form completed by a licensed MD or RN
- Dental Record Form completed by a dentist.
- Your child must be dismissed from their local school by you and a copy of the grades sent to the appropriate school in Wichita. The Cottage Parent will enroll your child in the local Wichita school.
- If the child is on any medications you will need to contact Dandurand Pharmacy the day you sign the admission papers to make billing arrangements.
- The Fee for Service is $1800.00 a month and the first month payment is due the day of the admission.
- Copy of the following:
- Birth Certificate
- Custody/ Adoption Papers
- Shot, including TB age 16 and older, and Immunization Records
- Insurance or medical card (front and back)
- Social Security Card
- Drivers License and auto insurance (when applicable)
