1229 Lincoln Hwy, PO Box 150 Van Wert, OH 45891

Phone: (419)238-1695 Fax: (419)238-1747

Email completed applications to:

APPLICATION FOR RESIDENTIAL SERVICES

Client’s Legal Name: / Date:
First / Middle / Last
Gender: M F / Birth Date: / Soc. Sec. No.: / - -
Address:
City, State, Zip: / County of Residence:
Client’s Race:
African Amer. Caucasian Multiple Race Asian Alaskan Native
Native Amer. Native Hawaiian/Other Pacific Islander Unknown
Client’s Ethnicity:
Puerto Rican Mexican Cuban Other Hispanic Not Hispanic or Latino
Authorized Representative/Legal Guardian’s Name:
Address:
City, State, Zip:
Phone No.: / () - / May we leave a message? yes no
Email Address:
In case of emergency or illness renders the client incapable of exercising treatment choices, we will contact Westwood Behavioral Health Crisis Intervention Services or Coleman Professional Services (after hours and weekends), or Van Wert County Hospital unless otherwise indicated below.
As client or Authorized Representative/Legal Guardian, I prefer The Marsh Foundation contact the following in case of emergency or illness during treatment:
Name: / Relationship to client:
Emergency Contact Phone No.: / () - / Address:
Is client in Children Services Custody? yes no Permanent Temporary
Is the placement court ordered? yes, attach copy of court order no
n/a / CASA worker/Guardian Ad Litem name:
Address: / Phone No.: / () -
Email Address:
n/a / Probation Officer name:
Address: / Phone No.: / () -
Email Address:
Who is responsible for payment of placement?
Funding source: Parent IV-E Cluster other, explain:
Permanency Plan:
Reunification Adoption Relative Placement Emancipation/Ind. Living PPLA Other

Family Information

Father’s Name: / Mother’s Name: / Maiden Name:
Address: / Address:
City, State, Zip: / City, State, Zip:
Phone No.: / () - / Phone No.: / () -
May we leave a message? yes no / May we leave a message? yes no
Employer: / Employer:
May we leave a message? yes no / May we leave a message? yes no
Work hours: / Work hours:
Parent’s Marital Status:
single married divorced widow separated common law other
If divorced or separated, what is the visitation plan?
List all others living in the home and their relationship to the client:
Client is a Victim of (check all that apply):
Neglect Abuse – Physical Abuse – Sexual Abuse – Emotional
None of the above Unknown
Has the client witnessed/experienced domestic violence? (check only one below)
yes, per report of child, family member, or other adult
yes, charges and/or restraining order issued
yes, convicted
none reported
History of drug/alcohol use/abuse of client?yesno
Substance use:
alcohol tobacco marijuana cocaine crack methamphetamine heroin
Is the client adjudicated dependent? yes no
Personal Risk Factors (check if applicable): gender issues sexual orientation issues

Client Behavior Information

Please list the client’s strengths:

Client’s areas of concern (check all that apply):

Developmentally Disabled / Speech impaired / Mental Illness/MR
Serious health issues / DUI/DWI / Deaf
Hearing impaired / Blind / Visually impaired
School drop out / Physically disabled / School behavior problems
Running away / Sexually active / Self-injurious behavior
Cruelty to animals / School expulsion / Stealing
Serious problem with authority / Gang involvement / Homicidal
Depression / School suspensions / Fire setting
Hallucinations / Verbally aggressive / Brain injury
STD’s (previous/current) / Pregnant / Fetal Alcohol Syndrome
Have children
Property damage, describe:
Physical aggression, describe:
Sexual perpetrator, describe:
Suicidal talk/threats/actions, describe:
other, describe:

Court involvement (check all that apply):

Status offender / Adjudicated delinquent – sex offense
Adjudicated delinquent – crime against person / Adjudicated delinquent – crime against property
Adjudicated delinquent – other / Probation
Parole / No court involvement due to status offense or delinquency

Documentation Needed for Application to be Processed

(Without all applicable documentation, the application is incomplete)

Psychological Evaluation/ Psychiatric Evaluation/ Psycho-Sexual Assessments
(Please provide evaluation/assessments or Release with name and address of person who conducted the evaluation/assessment.)
Juvenile probation records
Social history
Drug/alcohol counseling records
Previous placement documentation (hospitalizations, foster care, group homes, etc.)
School information/records
Copy of birth certificate
Copy of social security card
Does the client have Ohio Medicaid?
(If yes, please check appropriate managed care and attach a copy of card to the application)
Buckeye Health Plan CareSource Molina Healthcare
Paramount Advantage United Healthcare Community Plan
Does the client have private insurance? (If yes, please attach a copy to the application)
Does the client receive SSI? / Amount: / Payee:
Is there child support for this client? / Amount: / Payee:

Please use the space below to provide additional information from above listed items:

List the places and number of days the child has lived in the past 90 days beginning with the most recent:

Jail / Juvenile Detention / Inpatient Psych. Hospital
Drug/Alcohol Rehab. / Medical Hospital / Residential Treatment
Group Emergency Shelter / Residential
Job Corp/Voc Center / Group Home
Therapeutic Foster Care / Ind. Home
Emergency Shelter / Specialized Foster Care
Foster Care / Supervised Ind. Living / Home of Family Friend
Adoptive Home / Home of Relative / School Dormitory
Biological Father / Biological Mother / Two Biological Parents
Ind. Living with Friend / Ind. Living by Self

Why was the child removed from the most recent placement/living situation?

Planned discharge (successful) / Court removal / Self discharge
Withdrawal by placing agency / Administrative discharge by previous placement

Medical Information

Physician: / Dentist:
Address: / Address:
City, State, Zip: / City, State, Zip:
Phone No.: / () - / Phone No.: / () -
Date of Last Physical: / Date of Last Dental Exam:
Optometrist:
Address:
City, State, Zip:
Phone No.: / () -
Date of Last Optical Exam: / Does the Client wear/need glasses? yes no
Client’s height: / Client’s weight:
List any allergies the Client has:
List any physical problems, significant medical history or illnesses the Client has or has had:
Is the Client taking any type of medication? yes no
If yes above, list the prescribing physician, the medication, the dosage, thedate medication started, and the purpose:
Prescribing Physician / Medication / Dosage / Date Started / Purpose
Psychiatrist:
Address:
City, State, Zip:
Phone No.: / () -
Date of Last Visit:
List any psychiatric diagnosis, if applicable:

School Information

Legal First Name: / Soc. Sec. No.:
Legal Middle Name: / Eye Color:
Legal Last Name:
Date of Birth: / Gender: / M F / Race:
Mother’s Maiden Name:
Birthplace City, State, Zip:
Date admitted: / Date withdrawn:
School District of Residence (district responsible for payment):
School District Last Attended:
School Building Last Attended:
Address:
Current Grade Placement: / Client is: At Below Above current grade level.
Has Client been retained? yes no / If yes, which Grade?
Is Client on a current IEP? yes no / Client’s IQ (if known):
If no IEP, do you recommend that a Multi Factored Evaluation (MFE) be pursued? yes no
Special Education (if yes, what type):
Brief History of School Behaviors:
Father’s Name: / Mother’s Name:
Address: / Address:
City, State, Zip: / City, State, Zip:
Phone No.: / () - / Phone No.: / () -
Is the child in the legal custody of a government agency or person other than the child’s parent? yes no
If yes, list the name, address, caseworker’s name & phone number:
Agency Name: / Caseworker’s Name:
Address:
Is the placement court ordered? yes no If yes, please attach a copy of the court order.
Immunization dates: / Polio: / DPT: / MMR:

Marsh Foundation School

Release of Information

I authorize and grant permission to
(School Name)
to send the following information to The Marsh Foundation School.
Official transcript of grades, including any general test results
All health and other pertinent records, including immunization records
Any Individualized Education Plans (IEP)
Psychological evaluations
Social history or family background information
Proficiency results
Copy of social security card
This request is made in reference to the enrollment of
at The Marsh Foundation School. / (student’s name)
(Parent/Legal Guardian Signature) / (Date)

The Marsh Foundation School

Mr. Robbie Breese, Principal

PO Box 150

Van Wert, OH 45891

Phone: (419)238-1695 ext. 320

Fax: (419)238-3986