Completed Applications Can Be Returned to Me At

Thank you for your interest in our residential program at Arkansas Pediatric Facility. Below you will find an Application for Admission and an Authorization for Release of Information.

Completed applications can be returned to me at:

Arkansas Pediatric Facility

P.O. Box 6388

North Little Rock, AR 72124

Attn: Teri Loven, LSW

Or

You may fax them to 501-945-0219

Attn: Teri Loven, LSW

It would be helpful to the admission review committee if you could also include a copy of your child’s latest IEP and psychological evaluation. This information will be reviewed by the committee, and if the applicant is appropriate for our program, he/she will be placed on the waiting list.

I would be happy to arrange for a tour of our facility or meet with you to further discuss our program and facilitate the application process. You may contact me at 501-945-3177, if I can be of further assistance to you in this matter.

Sincerely,

Teri Loven, LSW

Director of Social Services

APPLICATION FOR ADMISSION

Applicant’s Name: ______Preferred Name: ______

Sex: Male Female DATE OF APPLICATION: ______

Birthdate: ______Place of birth : ______

Parent/Guardian’s Name: ______

Address : ______

Street, box #, etc. city county state zip

Telephone Numbers: ______

HOME WORK OTHER

Does applicant live with parents? ______If not where :______

Is applicant currently hospitalized or in a residential facility? ______

Where? ______

______

(please give address, phone #, and projected date of discharge)

DIAGNOSIS:______

At what age was applicant diagnosed: ______

FINANCIAL SOURCES: Medicaid SSI Social Security VA (check all that apply)

Private insurance Tefra child support trust account

Other: ______

Applicant’s Social Security number: ______
Applicant’s Medicaid number: ______

Private Insurance information: ______

Insurance company name

______

address subscriber’s name policy number

Who referred applicant to Arkansas Pediatric Facility?: ______

FAMILY DATA

Father’s Name: ______Birthdate: ______

Address ______SS # ______

City ______State ______Zip ______

Home telephone # ______Work telephone # ______

Employer ______Address ______

Occupation ______hours/days work______

Mother’s Name : ______Birthdate: ______

Address ______SS # ______

City ______State ______Zip ______

Home telephone # ______Work telephone # ______

Employer ______Address ______

Occupation ______hours/days work ______

Parents’ marital status: single married divorced separated widowed

Emergency Contact :______

phone # ______Relationship to applicant: ______

Address ______

List all siblings:

NameAgeFull/Half Sibling

______

______

______

______

______

List everyone who lives in the home with the child:

NAME AGE RELATIONSHIP OCCUPATION

______

Are there other relatives not in the home who show interest in the child? (grandparents, uncles, aunts, step-parents, brothers, sisters, etc.)

NAME RELATIONSHIP ADDRESS PHONE #

______

Why is application being made at this time? ______

______

What are your expectations if the child is admitted to APF? ______

______

What are your long range goals for this child? ______

______

Has the child ever been placed in a foster home or other residential facility?

yes no If yes, please give locations and dates: ______

______

______

MEDICAL INFORMATION:

Name of Primary Care Physician: ______

Phone Number :______Address: ______

Please list any social agencies, clinics physicians, dentists, psychologists, therapists with which your child has had contact:

Dates

Name/Agency Address City/State PH.# Seen

______

Pregnancy history of Mother:

Was mother under a physicians care during pregnancy? yes no

Was a physician present during delivery? yes no

Birth weight ______Duration of Pregnancy ______wks/mos______

Were there any illnesses, infections, unusual symptoms or problems during pregnancy?

______

Were there any problems during labor: yes no if yes, explain: ______

How long was the baby hospitalized at birth? ______

______

Name of Hospital Address

Has child ever had any of the following?

mumps measles chicken pox meningitis pneumonia bronchitis

flu vaccine

Is child current on all vaccinations? yes no

Please list current medications:______

______

Is child allergic to any foods or medications? yes no If yes, please list: ______

______

Please list surgeries and hospitalizations:

DATE / Diagnosis/ Surgeries / HOSPITAL

When did applicant last have the following examinations?

Date Where/Who Results

Eye Exam
Hearing Eval
Dental Exam
Swallow Study
Psych Eval.

THERAPY AND EDUCATIONAL INFORMATION:

Describe any of the following services your child is receiving or has received in the past:(include where, when and frequency)

Physical Therapy:______

______

Occupational Therapy: ______

______

Speech/Language Therapy:______

______

Has applicant attended a Kids First program, Public School Special Education, or Day Treatment School? (please tell when and where):

______

Please give names and addresses of any programs in which applicant is currently enrolled: ______

______

Please send a copy of the most recent Psychological evaluation report and IEP with this application, if you have it.

Does your child use any of the following special equipment?

wheelchair stander walker car seat hand splints AFO’s back brace hearing aide eye glasses lap tray

augmentative communication device

other, explain ______

Does applicant ……. Yes No With Assistance

Roll

Crawl

Stand

Pivot transfer

Walk

Propel wheelchair

What are the child’s skills in………

Independent needs assistance totally dependent

bathing

toileting

dressing

toothbrushing

hair care

feeding

does the child have problems with……

yes no explain

sucking ______

swallowing ______

chewing ______

gagging ______

biting ______

lip closure ______

drinking ______

Describe your child’s diet ( check all that apply):

tube fed bottle fed oral eater

strained baby food pureed/blended mashed

finely chopped coarsely chopped regular, cut into small pieces

thickened liquids must be fed by caregiver feeds self using spoon

feeds self using spoon & fork feeds self using fingers

drinks from a cup

How is applicant positioned during meals:

regular table/chair Wheelchair/table highchair

booster chair at table Wheelchair/tray feederchair

held in feeder’s lap

Does applicant drink formula? yes no type ______

List applicant’s favorite foods/flavors: ______

______

List any foods/flavors applicant dislikes: ______

______

BEHAVIORS

What does applicant do when he/she is:

Happy: ______

Angry: ______

Scared: ______

Sick: ______

Hungry: ______

Wet/Soiled: ______

With other children:______

Briefly describe your child’s bedroom and other rooms in the home (this helps us remind your child of his her environment and compare our facility to that which is familiar to your child) ______

______

Describe how your child sleeps (with light or radio on? With stuffed animal? What size bed?) ______
______

Describe activities that your child enjoys: (including outside activities like strolling, swinging etc.) ______

______

Briefly describe your child’s daily routine: (give approximate times of day) ______

What do you do when the child misbehaves? How do you discipline the child? ______

______

What do you do to calm your child down when he/she becomes upset? ______

What family activities does your child enjoy the most? ______
______

What is your child’s least favorite activity? ______

______

How does your child demonstrate dislikes? ______

What weekend activities does your child engage in that do not occur through the week? ______

List favorite toys or objects and briefly describe: ______
______

When not being attended to, your child is where, doing what? ______

______

______

Please provide any other important information regarding applicant which would be helpful to our staff: ______

______

Name of person completing application form.______

I certify that the above information is correct to the best of my knowledge:

Parent/Guardian Signature ______Date ______

Social Worker Signature ______Date Reviewed ______

AUTHORIZATION FOR RELEASE OF INFORMATION

CLIENT: ______DATE: ______

Date of Birth: ______

I, the parent/guardian of the above named client, hereby authorize Arkansas Pediatric Facility to obtain from any source, any medical or personal information deemed necessary for the care of this client. This is to include written and/or verbal communication in person and over the telephone. I also authorize Arkansas Pediatric Facility to release any medical or personal information to any facility or agency they deem appropriate.

______

Parent/Guardian Date

______

Witness Date

Please send the following information to: Arkansas Pediatric Facility

P.O. Box 6388

North Little Rock, AR 72124

Attn: Social Worker

______

______

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