Submitting...Validating Captcha...Authenticating...An error has occured. Details of this error have been logged.Submission Success!Person Completing This FormFirst Name*Middle NameLast Name*Phone Number*Email Address*Relationship to Child*How did you hear about the Village?Please select the source.*Through a Child Public Agency / Judicial SystemThrough a Hospital / Private Practice / Treatment SystemThrough a Search Engine / OtherPlease describe in detail.*Above, please include ... NAME OF ENTITY (county, hospital, private practice, treatment system, search engine, etc.) ... andYOUR CONTACT THERE (name, phone number, and email address), if applicable.How did you hear about the Village?Through a Child Public Agency / Judicial System?Name of CountyName of Your Contact TherePhone NumberEmail AddressThrough a Hospital / Private Practice / Treatment System?Name of Hospital / Private Practice / Treatment SystemName of Your Contact TherePhone NumberCurrent Grade LevelEmail AddressThrough a Search Engine / Other?Please describe.Child's InformationFirst Name*Middle NameLast Name*Date of Birth*Age*Gender*FemaleMaleChild's Address of Residence*City*State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherZip*Why do you feel this child needs residential treatment?*Child's Legal GuardianAre you the legal guardian?*YesNoDoes the child reside with you?*YesNoContact information for legal guardian, if someone other than you ...First NameMiddle NameLast NamePhone NumberEmail AddressAddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherZipInsurance InformationPolicy Holder NamePolicy Holder Date of BirthPolicy Holder AddressCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingOtherZipPrimary InsuranceInsurance CarrierGroup NumberMember IDMental Health Services Phone NumberMember Services Phone NumberSecondary InsuranceSecondary Insurance CarrierGroup NumberMember IDMental Health Services Phone NumberMember Services Phone NumberChild's School InformationType of School*PublicPrivateAlternativeHomeschool/HomeboundIf Public / Private / Alternative school ...Name of SchoolCurrent Grade LevelIf the child is currently suspended from school, please explain.If the child is not in the appropriate grade level, please explain.Grade AverageABCDFChild's IQ, If KnownDoes the child have an IEP or 504 plan?YesNoPlease describe current behaviors exhibited during learning times, and the frequency of these behaviors.Child's Current and Past Treatment ServicesPLEASE INCLUDE:Treatment provider's name, phone number, and email address.Services provided, service start date, and how many times per week.Current Treatment*RemoveAdd Another (4 remaining)Past Treatment*RemoveAdd Another (4 remaining)Child's Legal InvolvementDoes the child have any current legal involvement with the judicial system?CountyProbation Officer NamePhone NumberEmail AddressPlease describe the legal situation.Past or Present PetitionsRemovePlease include Court Hearing Date, Charge, and Explanation.Add Another (4 remaining)Is the child currently in a detention center?CountyPlease explain.Is the child currently in state custody?CountyCase Worker NamePhone NumberEmail AddressIs the child currently facing state custody?Date of Next HearingChild's Behavior HistoryAny aggressive behaviors in the past year (details)?Level of AggressionN/AMildModerateSevereTarget(s) of AggressionN/AFamilyPeersAuthority FiguresObjectsAnimalsHistory of setting fires or playing with fire (details)?Any plans to hurt others (details)?History of running away (duration, details of each incident)?RemoveAdd Another (9 remaining)Exhibited any sexually inappropriate behavior (date, details of each incident)?RemoveAdd Another (9 remaining)Experienced any sexual abuse (date, details of each incident)?RemoveAdd Another (9 remaining)Experienced any trauma or abuse (date, details of each incident)?RemoveAdd Another (9 remaining)Any attempted suicide or suicidal ideation/thoughts (date, details of each incident)?RemoveAdd Another (9 remaining)Any episodes of self harm (date, details of each incident)?Any gang involvement (details)?Child's Health HistoryWhat is the current mental health diagnosis (details)?Any eating disorder concerns (details)?Irregular sleeping patterns (details)?Prescription medication (name, dosage, frequency, reason for use, any compliance issues)?RemoveAdd Another (9 remaining)Any type of injections required (details)?Any allergies – seasonal, foods, medications (details)?Ever any anaphylactic reaction to any allergens (details)?Any physical disabilities – prosthetic limbs, broken bones, cast, boot (details)?History of seizures (details, date of last seizure)?Any brain or head injuries (date, details)?Any surgeries (date, details)?If the child is diabetic ...Is the child currently on medication for diabetes?YesNoIs the diabetes controlled by the medication?YesNoName of Diabetes SpecialistPhone NumberDate of Last Follow-Up Doctor AppointmentAre there any other health concerns we need to be made aware of before admission?Substance AbuseAny alcohol abuse (type of alcohol, date, frequency of use, details)?RemoveAdd Another (9 remaining)Any drug abuse (type of drug, date, frequency of use, details)?Documents / RecordsIf you have any recent documents and/or records that may help in the admissions process (for example, recent discharge paperwork or psychological evaluation), please email them to Cayla.Smith@villagebh.com.