Thank You for Your Interest in Patrick Henry Family Services. I Am Enclosing an Application

860 Red Hill Road

Brookneal, VA 24528

434.376.2006 ext. 308

Fax 434.376.3003

Thank you for your interest in Patrick Henry Family Services. I am enclosing an application to Patrick Henry Boys and Girls Homes and some literature so that you can better understand our ministry to families.

Our program is a substitute program that models Christian family life for children who are unable to function in their current setting. We accept children into care from ages five through seventeen who have a specific need that cannot be met in their current setting, but who are not delinquent, substance abusers, or in need of a treatment facility. Our program is specifically designed to provide children in high risk environments with a “preventative residential setting.” Our children attend local public schools, attend a local church, and participate in other community activities.

Please contact us between 8:30 AM and 5:00 PM at 434.376.2006, Monday through Friday. To begin the process, we will need followings forms sent us complete with name, location, phone number, your signature, and date: Application and Consent for Release of Information.

Sincerely,

Crystal Boyd

Patrick Henry Family Services

Application Checklist

Below is a list of things that we will need to consider your applicant for placement.

_____ Application

_____ Original Birth Certificate

_____ Original Social Security Card

_____ Photo ID (school or DMV)

_____ Copy of Insurance, Dental, and Prescription cards (front and back)

_____ CustodyDecree

_____ Interview at PHBGH with parent and child

_____ Medical Records, including immunizations

_____ Physical on PHFS form-this can be no older than 90 days at the time of admission (Please make sure nothing is left blank)

_____ Dental Cleaning on PHFS form- this can be no older than 6 months at the time of admission

_____ Psychological Records, if any

_____ Counseling Records, if any

_____ Cumulative School Records, including discipline and IEP/504 if applicable

_____ Proof of Medical Insurance

If you will be needing Financial Assistance, the following information will be required.

_____ Current Tax Return

_____ Completion of Financial Assistance Request Form

On the Date of Admission you will sign a packet of paperwork including, but not limited to:

_____ PHFS Entrustment Agreement

_____ PHFS Financial Assistance Agreement

Patrick Henry Family Services

Application for Admission

860 Red Hill Road Brookneal, VA 24528

434.376.2006 Ext. 308 434.376.3003 Fax

This application for admission to Patrick Henry Family Services is being made for (complete name of child) ______. I certify that I have the authority to make application on behalf of this child and that all information is complete and accurate to the best of my knowledge.

______(Signature)

______(Relationship) ______(Date)

This application will be active for a six week period during which time all admissions information must be received.

FAMILY INFORMATION:

Child’s Name: ______

Last, First, Middle

Gender: □ M □F Date of Birth: ______Birth Place: ______Social Security Number: ______

Legal custody held by: ______Relationship: ______

Address: ______

City, State, Zip:______, ______, ______

Phone number: _____ - _____ - ______

Is child covered by your insurance? □ Medical □ Dental □ Vision □ Prescription

Medical Insurance Name:______Policy Number:______

FATHER: Name: ______

Last, First, Middle

Date of Birth: ______Birth Place: ______

Address: ______

City, State, Zip______, ______, ______

Phone number: _____ - _____ - ______

Marital Status: □ Single □ Married □ Divorced □ Separated

Education (circle last year completed): 1 2 3 4 5 6 7 8 9 10 12 College 1 2 3 4 5 6

Health:□ Excellent □Good □ Fair □ Poor Deceased: □ Yes □ No

If yes, Date______Cause of Death: ______

MOTHER: Name ______

Last, First, Middle

Date of Birth: ______Birth Place: ______

Address: ______

City, State, Zip:______, ______, ______

Phone number: _____ - _____ - ______

Marital Status: □ Single □ Married □ Divorced □ Separated

Mother’s Education (circle last year completed): 1 2 3 4 5 6 7 8 9 10 12 College 1 2 3 4 5 6

Health:□ Excellent □Good □ Fair □ Poor Deceased: □ Yes □ No

If yes, date:______Cause of Death: ______

CHILD’S EDUCATION: Years in school: __ Grade __ List any grades repeated ______

Name of Current School:______Phone number:_____ - _____ - ______

Scholastic Performance: ______

Conduct (Behavior):______

Describe child’s attitude towards school :______

BROTHERS AND SISTERS (child’s)

Name Birth date Address Grade Health

______

I UNDERSTAND THAT THE INFORMATION OBTAINED DURING THE APPLICATION PROCESS MAY BE SHARED WITH OTHER STAFF MEMBERS AT PATRICK HENRY FAMILY SERVICES AS PART OF THE ADMISSION PROCESS.

______(Signature)

______(Relationship) ______(Date)

II. PERSONALITY INFORMATION:

Circle any of the following words which best describe your child:

hyper-activeambitiousself-confidentpersistentnervoushardworking,

impatientimpulsivemoodyexcitablegoodimaginative,

often - blue, calm,serious,shy sensitiveeasy going

good natured introvert extrovertlikableleader,quiet

submissivelonelyself-consciousactive

Other: ______

Describe the child: ______

______

Alcohol/drug use? □ Yes □No □ Current □ Past

Please explain: ______

______

Legal charges? ______Past legal charges ______

If yes, please explain: □ Yes □No □ Current □ Past

Please explain: ______

______

III. PSYCHOLOGICAL INFORMATION:

Has child had a Psychological Evaluation, I.Q. or Personality test? □ Yes □No

Date: ______Test Conducted by: ______

IV. MEDICAL

Is child currently taking any medications? □ Yes □No

List medications, dosage and prescribing physician:

1. ______