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Student's Name *
Student's Name
Student's Address
Student's Address
Phone
Phone
Student Identity
Emergency Contact
Name
Name
Address 1
Address 1
Phone
Phone
Parent/Guardian/Sponsor
Name
Name
Address
Address
Mobile Phone
Mobile Phone
DOB
DOB
Work Phone
Work Phone
Referral Information
Family Information
Parent's Martial Status
If divorced or separated, please provide the date
If divorced or separated, please provide the date
Is your child adopted
where was your student born?
where was your student born?
Educational Information
What is the highest level of schooling your student has completed?
Name of School
Name of School
School Address
School Address
http://
School Contact
School Contact
Does Integrated Interventions have permission to contact your students current and previous school for academic, interventions, etc, about the applicant?
Is your student behind in credits?
Favorite Subjects:
Least Favorite Subjects:
School Information
Elementary: - -Student's Strengths: -Challenges: Middle School: - -Student's Strengths: -Challenges: High School: - -Student's Strengths: -Challenges:
If yes, please give dates and reasons:
If yes, please describe all tests (include Name/Type of Test, Date Given, Contact Phone):
*Note: Please fax/mail/e-mail a copy of these tests as part of your application.
Placement Information
Last known address of the child (address at time of admission):
Last known address of the child (address at time of admission):
Placement/Intervention History
Please list all previous, relevant placements and/or interventions (including home therapists, psychiatrists, etc.):
Can we contact?
Location of Treatment
Location of Treatment
Date Student Entered Treatment
Date Student Entered Treatment
Date Student Exited Treatment
Date Student Exited Treatment
May We Contact
Location Of Treatment
Location Of Treatment
Date Student Entered Treatment
Date Student Entered Treatment
Date Student Exited Treatment
Date Student Exited Treatment
Can we contact?
Location of Treatment
Location of Treatment
Date Student Entered Treatment
Date Student Entered Treatment
Date Student Exited Treatment
Date Student Exited Treatment
If yes, please describe (include date/reason):
*Note: Please fax/e-mail/mail all previous testing from the last 3 years as part of this application Ethnicity, race, religion, nationality, or sexual orientation. Please describe anything of note:
Please describe any major events your child has struggled with (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.) Please include the date the event occurred:
If yes, please describe:
If yes, please describe (include date/reason):
If yes, please describe (specify date, how long, where, contacted you?, etc.):
If yes, please describe (specify date/reason):
If yes, please describe:
If yes, please describe in detail including dates:
If yes, please describe in detail including dates:
If yes, please describe in detail:
If yes, describe when you first noticed substance use and the choice of substance, usage patterns/frequency and how administered; please include cigarette use:
If yes, please describe (include who/relationship, problem area, current status):
If yes, please describe:
If yes, please list any charges, convictions, misdemeanors, felonies, probation and current legal status:
If yes, please describe (include who/relationship, problem area, current status):
Medical Information
Date of last physical:
Date of last physical:
Please include date/event:
If yes, please describe:
(include name of medication, dosage, reason, prescribing physician)
If yes, please describe:
If yes, please describe:
Is your child up-to-date on immunizations?
List all allergies (food, medication, grasses, etc.), how activated and what happens:
Please list name/type of inhaler:
If yes, please describe (include date/reason):
Please list any pertinent medical history in your child's family:
Insurance Information
Insurance Provider Address
Insurance Provider Address
Phone:
Phone:
Does your child currently have or ever had any of the following? (check box if yes):
Secondary Insurance Company:
Insurance Provider Address
Insurance Provider Address
Phone 6
Phone 6
Policyholder's Date of Birth:
Policyholder's Date of Birth: