Genesis Youth Crisis Center, Inc.
DBA: Alta Vista Children’s Shelter
P.O. Box 546 ~ 261 Haymond Highway ~ Clarksburg, WV 26302
Phone (304) 622-3339 ~ Fax (304) 622-3433
ADMISSION REPORT
Identification Information:
Resident Name___________________________ Admission Date____/____/____
Program Alta Vista Children’s Shelter Medicaid #________________________
County of Residence_______________________ Social Security #____________________
D.O.B____/____/____ Age____ Sex: M F Race: ( ) White ( ) Black ( ) Hispanic
Religion________________________________________ ( ) Asian ( ) Other
Place of Birth___________________________________
Legal Information:
Legal Custody Status__________________________________ ( ) Temporary ( ) Permanent
DHHR Worker _______________________________________ Phone______________________
Address_______________________________________________________________________
Juvenile Probation Officer______________________________ Phone______________________
Circuit Court Judge____________________________________ Phone______________________
Resident’s Attorney____________________________________ Phone______________________
Presenting Problems (Identify current problems which led to placement):
( ) Physical Abuse ( ) Neglect ( ) Sexual Abuse ( ) Truancy ( ) Incorrigibility
( ) Runaway ( ) Sex Offense ( ) Criminal Acts ( ) Behavioral ( ) Other
Explain Reason for shelter placement______________________________________________________
Describe any behavioral problems_________________________________________________________
Pending Status Offense/Criminal Charges___________________________________________________
Discharge Plan_________________________________________________________________________
Family Information:
Name and Address of Mother_____________________________ Marital Status____________________
_____________________________________________________ Phone__________________________
Name of Step-Father (if living with mother or involved with child)________________________________
Name and Address of Father _____________________________ Marital Status____________________
_____________________________________________________ Phone__________________________
Name of Step-Mother (if living with father or involved with child)________________________________
Name and ages of Siblings (Also may identify other family members who are involved with child)
_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Medical/Treatment Information:
Does the child have any condition which requires special needs? ( ) No ( ) Yes ___________________
Has the Child had an EPSDT? ( ) No, needs one ( ) Yes Date of Exam___________________________
(Please provide a copy of EPSDT report, if available)
ADMISSION REPORT
Is the child on any medication at this time? ( ) No ( ) Yes
Were all medications/prescriptions brought with the child? ( ) No ( ) Yes
List all medications: __________________________________________________________________________________________________________________________________________________________________________
Other Medical Needs? ( ) Dental ( ) Optical ( ) Other
Has the child had a Psychological Evaluation? ( ) No, needs one ( ) Yes Date of eval/Availability____
Is the child currently attending Individual/Group/Family counseling ( ) No ( ) Yes
If yes, where/with whom___________________________ Is this to continue? ( ) No ( ) Yes
Other Psychological/Treatment needs? __________________________________________________________________________________________________________________________________________________________________________
Education:
Last school attended/County_____________________________________________________________
Current Grade_________________________________ ( ) Special Education ( ) L.D. ( ) B.D.
Child’s History:
( ) Physical Abuse ( ) Neglect ( ) Sexual Abuse ( ) Truancy ( ) Incorrigibility
( ) Runaway ( ) Sex Offence ( ) Criminal Acts ( ) Behavioral ( ) Other
Prior out of home placements (including name/type of placement and dates):
__________________________________________________________________________________________________________________________________________________________________________
Prior Adjudications (indicate charge and date):
__________________________________________________________________________________________________________________________________________________________________________
Please provide any additional information which may be helpful for the care and treatment of the child during this placement:
__________________________________________________________________________________________________________________________________________________________________________
_____________________________________________________________________________________
______________________________________________________ __________________________
Legal Guardian Date
______________________________________________________ __________________________
Case Manager Date