Residential Treatment for Youth
P.O. Box 86 Hiddenite, NC 28636
Phone (704) 224-2364 Fax (828) 352-9515
Application for Admission
Date of Application: _____
Applicant's Name: ______County: ______
Social Security ______Religion: ______
Date of Birth: ______
Briefly state reason(s) for seeking admission: ______
______
______
______
______
Primary Diagnosis: ______
______
______
-Family Background-
Father’s Name:______Social Security ______
Occupation: ______Business Phone: ______
Home Address:______Home Phone: ______
Mother's Name:______Social Security: ______
Occupation: ______Business Phone: ______
Home Address: ______Home Phone: ______
Additional Family Members (please include name, age, address, and relationship to applicant):
______
______
-Other Identifying Information-
1.Social History
a)Please describe the current living arrangements for the applicant (e.g. at home, with relatives, institution, etc.): ______
______
How often does applicant see family members? ______
______
c)Please give an estimation of how many days per year the applicant will be going home for overnight visits (e.g. Weekends, Christmas, Thanksgiving, birthdays, etc.): ______
______
d ) Including both family and non-family members, please list the most
important people in the applicant’s life and what their relationship is to the
applicant:______
______
e)If applicant has a court appointed legal guardian, please give the name, address,
And relationship to the applicant: ______
______
2.Developmental Training of Applicant:
a) Educational training (include name of program, address, and dates attended): ___
______
______
______
______
______
b) Work experience (include employer's name, address, and dates attended): ______
______
______
______
1
3.Physical and Mental Capabilities:
a)Check (,/) the appropriate box that best describes applicants current functioning
status:
DISORIENTENT AMBULATION STATUS BLADDER
___ Constantly _____ Non- -Ambulatory _____ Requires Constant Diapering
___ Intermittently _____ Needs Assistance _____ Nights Only
with Transfers _____ Occasional Incontinence
INAPROPRIATE BEHAVIOR DIETARY NEEDS
____Wanderer _____ Diabetic
____Verbally Abusive _____Requires Special Diet
____Injurious to Others _____Allergic to Certain Foods
____Injurious to Property
BOWEL INCONTINENCE COMMUNICATION OF NEEDS
____More Often Than One/Week _____ Verbally
____Less Than One Week _____ Non-Verbally
_____ Does Not Communicate
b). If any of the above boxes are checked ( ), please describe in further detail: ______
______
______
______
______
______
______
______
______
______
______
______
1
c) Check ( ) the appropriate box that best describes applicants current functioning status: ____Independent Toileting _____Some Cooking Skills
____Independent Feeding _____Signs Name
____Independent Bathing _____Tells Time
____Independent Dressing _____Responds to Instructions
____Chooses Proper Clothing _____Can Communicate Needs
____Cares For Personal Belongings
d)What goals are the applicant presently working toward? Are there areas where the applicant needs improvement? ______
______
______
______
e)Has the applicant ever been treated by a psychiatrist a state hospital, or mental retardation center, or a mental health center? Please explain: ______
______
______
______
Please comment on applicant’s ability to get along with others: ______
______
______
g) List interests and hobbies of the applicant: ______
______
______
4.Medical History:
a)Describe any past hospitalizations and operations of applicant:
Month & Year Type or Reason Name of Hospital
______
______
______
______
1
b)Does applicant have any medical condition which requires on-going
Nursing care? Please specify:______
______
______
______
______
______
c) Convulsive History- if any, please give:
Age of onset: ______
Type and Frequency: ______
Is it controlled? ______
d)Any known allergies (including drug & food allergies). Please describe: ______
______
______
______
e)Does applicant take medication for any on-going problems? if so, please give:
MEDICATIONDOSAGE HOW OFTEN REASON FOR TAKING
______
______
______
______
______
______
f)place a check ( ) Please in the front of all of the following tests and immunizations
Applicant has had and give the last year they received them:
( )YEARTESTYEAR IMMUNIZATION
____ Physical Exam ______Tetanus Shot
____ Chest X-Ray ______DPT
____ TB Skin Test ______Hepatitis B
______FLU
______Polio
g) Has applicant been screened for Hepatitis B? _____if not, screening
may be requested upon acceptance into any CLN,LLC program.
5.Financial Resources of Applicant
a) Income:
Source
Social Security$______
Social Security Income $______
Earned Income$______
Other$______
MedicaidYes______No______
b) Property
1)Real Estate (include value): ______
______
2) Other: ______
______
6.Legal Status
a) Is the applicant a U.S. Citizen?______If not, what is the citizenship
status of the applicant? ______
b) Has the applicant ever been arrested?______If so, please give details:______
______
______
______
I certify that all pertinent information in the areas of behavioral problems, sexual problems, physical capabilities, psychological difficulties, and any incidents which may have occurred in these areas have been given to the Admissions Committee of Changing Lives Now, LLC.
1
Information has been withheld.
I hereby apply for admission to a program operated by Changing Lives Now, LLC. I agree to abide by the rules and regulations of the program, and understand that violations of the rules can result in discharge from the program.
______
Date Signature (or mark) of Applicant
______
Date Signature of Parent or Guardian
______
Date Signature of Persons Completing Application
______
Relationship to Applicant
Changing Lives Now, LLC. complies with the requirements of Title V1 of the Civil Rights Act of 1964 and Section 504 of the Rehabilitation Act of 1973.
Office Use Only
Date Received ______
Reviewed by ______
Referral Source ______
Disposition ______
1