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CHILD APPLICATION

CHILD:

FULL LEGAL NAME_________________________________________________________________________________

 

AGE ______GRADE_________________DOB_______________________BIRTHPLACE__________________________

 

 SS NUMBER _____________________SEX__________RACE_______________RELIGION________________________

 

HEIGHT _____________WEIGHT_________      HAIR _______________________EYE COLOR______________________

 

 DISTINGUISHING MARKS____________________________________________________________________________

 

LAST RESIDED WITH _________________________________RELATIONSHIP_________________________________

 

 ADDRESS________________________________________________________________________________________

 

HOME PHONE ______________________________CELL PHONE_____________________________________________

 

 LEGAL GUARDIAN _____________________________RELATIONSHIP_______________________________________

 

 ADDRESS ____________________________________________HOME PHONE________________________________

 

PRIOR PLACEMENTS (Include foster care, hospitalizations, etc.):

                            Name                                                                       Address                                                                                Date

(1) ________________________________________________________________________________________________

 

(2) ________________________________________________________________________________________________

 

(3) ________________________________________________________________________________________________

 

(4) ________________________________________________________________________________________________

 

DHS OR CPS CUSTODY-________________DATE/S__________________________________________________________

 

 PLACEMENT REASON _______________________________DISCHARGE REASON_______________________________

 

 COURT RECORD ___________________DATE/S _____________________REASON/S_____________________________

 

 CASE WORKER/PO NAME _______________________________________PHONE #_______________________________

 

 REASON____________________________________________________________________________________________

HOW DOES CHILD FEEL ABOUT PLACEMENT AT TIPTON HOME?____________________________________________________________________________________________________

 

____________________________________________________________________________________________________

PRESENTING PROBLEM:   DESCRIBE REASON FOR PLACEMENT AT THE TIPTON HOME.

 ____________________________________________________________________________________________________

 

 ____________________________________________________________________________________________________

 

 ____________________________________________________________________________________________________

 

 ____________________________________________________________________________________________________

 

 LIST CHILD’S INTERESTS, HOBBIES, ETC. (1)_____________________________________________________

 

(2)___________________________________________(3)__________________________________________

FAMILY HISTORY:  RELATIVES OR OTHER INTERESTED PERSONS

                            NAME                         RELATION                                                       ADDRESS                                                PHONE                              

(1)___________________________________________________________________________________________________ 

                                                               

(2)___________________________________________________________________________________________________ 

    

                                     NAME                                              DOB                                      ADDRESS                                              PHONE

SIBLINGS: (1)__________________________________________________________________________________________

 

(2)___________________________________________________________________________________________________

 

(3)___________________________________________________________________________________________________

 

(4) ___________________________________________________________________________________________________

 

(5) ___________________________________________________________________________________________________

 

 BIRTH ORDER: ONLY; 1ST; 2ND; 3RD; 4TH; 5TH; 6TH; 7TH;BABY, ADOPTED, TWIN

 BIOLOGICAL MOTHER: ________________________________________________________________________                                                                                                                                     NAME                                                         DOB                                                  SS#

 ________________________________________________________________________________________________________________________                                                                                                                        ADDRESS                                                                                       HOME PHONE                                            CELL PHONE

________________________________________________________________________________________________________________________                                                                                                                    OCCUPATION                                                                EMPLOYER

 ________________________________________________________________________________________________________________________                                                                                      SALARY                                                                WORK PHONE                                                    LENGTH OF EMPLOYMENT

IF DISABLED, DECEASED, INCARCERATED, OR UNEMPLOYED GIVE DATES, AGE OF CHILD AT ONSET AND

REASON/S

_______________________________________________________________________________________________________

 

_______________________________________________________________________________________________________

 

NAME OF SPOUSE/LIVE IN  _________________________________________________________________________________

 

BIOLOGICAL FATHER: ___________________________________________________________________________                                                                                                                                     NAME                                                                DOB                                             SS#

 ________________________________________________________________________________________________________________________

                            ADDRESS                                                                                       HOME PHONE                                              CELL PHONE

 

________________________________________________________________________________________________________________________

                          OCCUPATION                                                                                           EMPLOYER

 _________________________________________________________________________________________________________________________                                                                                       SALARY                                                                WORK PHONE                                                    LENGTH OF EMPLOYMENT

 

IF DISABLED, DECEASED, INCARCERATED, OR UNEMPLOYED GIVE DATES, AGE OF CHILD AT ONSET

AND REASON/S

_________________________________________________________________________________________________________

 

_________________________________________________________________________________________________________

 

NAME OF SPOUSE/LIVE IN  __________________________________________________________________________________

FAMILY-OF-ORIGIN PSYCHO/SOCIAL/MEDICAL HISTORY:

                 MOTHER                FATHER        SIBLING 1          SIBLING 2         P/M AUNT/UNCLE             P/M GRANDMOTHER/FATHER

DRUG  USE_________________________________________________________________________________________________

 

DIVORCE__________________________________________________________________________________________________

 

SEXUAL ABUSE____________________________________________________________________________________________

 

MENTAL DISORDER_________________________________________________________________________________________

 

EDUCATION LEVEL__________________________________________________________________________________________

 

TEMPERAMENT______________________________________________________________________________________________

 

COUNSELING_______________________________________________________________________________________________

 

DIABETES OR TB____________________________________________________________________________________________

 

HEPATITIS A B C____________________________________________________________________________________________

 

FINANCIAL:  IS CHILD ENTITLED TO ANY AID FROM:

(1) SOCIAL SECURITY ______________________AMOUNT $____________ ______SS#___________________________________

 

NAME OF BENEFACTOR ______________________________________________________________________________________

 

(2) VETERANS BENEFITS ____________________AMOUNT $_________________ CLAIM#________________________________

 

SOURCE NAME______________________________________________________________________________________________

 

(3)CHILD SUPPORT _________________________AMOUNT $___________________SS#__________________________________

 

NAME OF BENEFACTOR ______________________________________________________________________________________

 

(4) OTHER SOURCE OF INCOME __________________________________________AMOUNT $_____________

 

****I CERTIFY THAT I AM NOT UNDER ANY FINANCIAL OBLIGATION WHILE MY CHILD

IS A RESIDENT AT THE TIPTON HOME THEREFORE, I WILL PROVIDE $0 TOWARDS

THE CHILD’S SUPPORT.

 

SIGNATURE ______________________________________________DATE____________________________

 

EDUCATION:      USUAL GRADES OF STUDENT  [ A   B   C   D   F  ]

 

HAS THE CHILD EVER:

 

REPEATED A GRADE ________ WHICH ONE/S _________________________________________________________________________

 

BEEN IN SPECIAL ED OR REMEDIAL CLASS? _____________BEEN IN GIFTED OR TALENTED CLASSES _____________

 

WHEN___________________                   BEEN IN SPEECH THERAPY CLASS_____________

 

BEEN A DISCIPLINE PROBLEM AT SCHOOL ____________IF SO, EXPLAIN _________________________________________________

 

______________________________________________________________________________________________________________

BEEN SUSPENDED ( ) EXPELLED ( ) IN-SCHOOL DETENTION ( ) SATURDAY SCHOOL ( ) TRUANT ( )

 

EXPLAIN ______________________________________________________________________________________________________

 

CURRENT SCHOOL AND ADDRESS ________________________________________________________________________________

 

PREVIOUS SCHOOL/S: _________________________________________________________________________________

                                                       NAME                                                           ADDRESS                                               DATES ATTENDED

 

__________________________________________________________________________________________________

                                                       NAME                                                           ADDRESS                                               DATES ATTENDED

 

__________________________________________________________________________________________________

                                                       NAME                                                           ADDRESS                                               DATES ATTENDED

 

__________________________________________________________________________________________________

                                                       NAME                                                           ADDRESS                                               DATES ATTENDED

 

MEDICAL HISTORY:  REGULAR PHYSICIAN ________________________________ADDRESS _____________________________

 

DO YOU HAVE HEALTH INSURANCE WHICH CARRIES THE CHILD AS A DEPENDENT?   Y N

 

NAME OF INSURANCE ____________________________________________________POLICY#______________________

HAS THE CHILD HAD THE FOLLOWING?

                                                        DATE/S                            DR. & LOCATION/S                                 REASON/S

SERIOUS ILLNESS/S Y N______________________________________________________________________________________

 

BROKEN BONE/S Y N_______________________________________________________________________________________

 

HOSPITALIZATION/S Y N ___________________________________________________________________________________

 

SURGERIES Y N ____________________________________________________________________________________________

 

IMMUNIZATIONS Y N _______________________________________________________________________________________

 

A HANDICAP Y N __________________________________________________________________________________________

 

TETANUS SHOT Y N ________________________________________________________________________________________

 

DOES THE CHILD HAVE ANY MEDICAL, DENTAL, VISUAL OR PSYCHOLOGICAL PROBLEMS?

Y N  IF YES, PLEASE EXPLAIN __________________________________________________________________________________

 

__________________________________________________________________________________________________________

 

LIST ANY MEDICATION THE CHILD IS CURRENTLY TAKING OR HAS EVER TAKEN:

 

NAME: __________________________________REASON__________________________________________________________

 

DR. WHO PRESCRIBED IT ___________________________________________________________________________________

 

HOW LONG HAS CHILD BEEN TAKING THIS PRESCRIPTION?_______________________________________________________

 

NAME:__________________________________REASON_________________________________________________________

 

DR. WHO PRESCRIBED IT ___________________________________________________________________________________

 

HOW LONG HAS CHILD BEEN TAKING THIS PRESCRIPTION?_______________________________________________________

 

NAME: __________________________________REASON__________________________________________________________

 

DR. WHO PRESCRIBED IT ____________________________________________________________________________________

 

HOW LONG HAS CHILD BEEN TAKING THIS PRESCRIPTION?_______________________________________________________

 

NAME: __________________________________REASON__________________________________________________________

 

DR. WHO PRESCRIBED IT ____________________________________________________________________________________

 

HOW LONG HAS CHILD BEEN TAKING THIS PRESCRIPTION?_______________________________________________________

 

IS THE CHILD ALLERGIC TO MEDICATIONS, FOODS, BEE STINGS OR OTHER? (CIRCLE THAN EXPLAIN)

 

______________________________________________________________________________________________________

 

DOES THE CHILD WEAR GLASSES/CONTACTS? Y N IF YES, WHEN WAS CHILD’S LAST EXAM?____________

 

DR. __________________________________ADDRESS________________________________________________________

 

DOES THE CHILD WEAR BRACES? Y N  LAST DENTAL EXAM_________________________________________

 

DENTIST NAME _________________________ADDRESS____________________________CAVITIES? Y  N

 

HAS THE CHILD ATTENDED COUNSELING?  Y N HAD A PSYCHOLOGICAL EVALUATION?  Y  N

 

PSYCHOLOGIST NAME AND ADDRESS _______________________________________________________________

 

__________________________________________________________________________________________________

 

DOES THE CHILD HAVE ANY TATTOOS? Y N  DATE OF EACH ______________________________________________

 

DONE PROFESSIONALLY OR HOMEMADE? _______________________________________________________________

 

DOES THE CHILD HAVE OR EVER HAD ANY PROBLEM WITH THE FOLLOWING:

 

YES    

 NO

DESCRIPTION AND DATE OF ONSET

ALLERGIES

______

______

__________________________________________________________

 

ASTHMA

______

______

__________________________________________________________

 

DIABETES 

______

______

__________________________________________________________

 

HEART PROBLEMS           

______

______

__________________________________________________________

 

HEARING LOSS                   

______

______

__________________________________________________________

 

WHOOPING COUGH

______

______

__________________________________________________________

 

SEIZURES

______

______

__________________________________________________________

 

MEASLES

______

______

__________________________________________________________

 

EAR TROUBLE                     

______

______

__________________________________________________________

 

FAINTING SPELLS

______

______

__________________________________________________________

 

DIPTHERIA

______

______

__________________________________________________________

 

THROAT TROUBLE

______

______

__________________________________________________________

 

CHICKEN POX

______

______

__________________________________________________________

 

MUMPS

______

______

__________________________________________________________

 

KIDNEY PROBLEMS

______

______

__________________________________________________________

 

RHUMATIC FEVER

______

______

__________________________________________________________

 

SMALL POX 

______

______

__________________________________________________________

 

HAY FEVER 

______

______

__________________________________________________________

 

INFANTILE PARALYSIS

______

______

__________________________________________________________

 

SCARLETT FEVER

______

______

__________________________________________________________

 

HIGH BLOOD PRESSURE

______

______

__________________________________________________________

 

HYPERACTIVE/ADHD      

______

______

__________________________________________________________

 

ALCOHOLISM

______

______

__________________________________________________________

 

AIDS/HIV OR STD’S           

______

______

__________________________________________________________

 

TUBERCULOSIS

______

______

__________________________________________________________

 

HEPATITIS A B C                   

______

______

__________________________________________________________

 

SEXUAL RELATIONS           

______

______

__________________________________________________________

 

ABORTION/S                         

______

______

__________________________________________________________

 

INCESTUOUS RELATIONS

______

______

__________________________________________________________

 

INTRAVENOUS DRUG USE

______

______

DATE OF LAST USE ____________________________

 

HAS CHILD STARTED HER PERIOD YET?

______

______

 

DATE OF LAST MENSTRUAL CYCLE ____________________ # OF DAYS (             ) AGE OF ONSET ______________

 

POSSIBILITY OF BEING PREGNANT? ________ DATE OF LAST INTERCOURSE ____________________________

 

DESCRIBE CHILD’S SEXUAL PECULLARITIES OR IDEATIONS _______________________________________________

 

_________________________________________________________________________________________________

HAS THE CHILD USED/OR IS CURRENTLY USING UNPRESCRIBED DRUGS, ALCOHOL, OR ANY

FORM OF TOBACCO? (EXPLAIN_______________________________________________________________________________________

HAS THE CHILD BEEN ABUSED?

 

PHYSICALLY? ________________________________________________________________________________

 

EMOTIONALLY? ______________________________________________________________________________

 

SEXUALLY? ________________________________________________________________________________

 

SPIRITUALLY? _______________________________________________________________________________

 

HAS THE CHILD THREATENED SUCIDE? Y N  IF YES, HOW MANY TIMES (_______) PLEASE  EXPLAIN____________________________________________________________________________________

 

___________________________________________________________________________________________

 

WHAT WAS HAPPENING WITH THE FAMILY AT THAT TIME? ________________________________________

 

____________________________________________________________________________________________

_____________________________________________________________________________________________

 

HAS THE CHILD RAN AWAY OR THREATENED TO RUN AWAYY  N

IF YES, HOW MANY TIMES (_______) PLEASE  EXPLAIN ______________________________________________

 

______________________________________________________________________________________________

 

______________________________________________________________________________________________

 

WHAT WAS HAPPENING WITH THE FAMILY AT THAT TIME? _________________________________________

 

______________________________________________________________________________________________

 

______________________________________________________________________________________________

 

 This is a list of problems that the child may or may not be having. Please indicate the frequency

of each problem by circling the appropriate number. Rate the following on a 0-10 scale

system: 0=never, 1=rarely, 2-3=seldom, 4-5=occasionally, 6-7=often, 8-9=frequently,

10=always/extremely.

 

DATE OF ENTRY ___________PERSON/S ANSWERING _________________________________________________

1

AFRAID OF NEW SITUATIONS……

0

1

2

3

4

5

6

7

8

9

10

 

 2

WORRIES TOO MUCH………………

0

1

2

3

4

5

6

7

8

9

10

 

 3

SAD OR UNHAPPY MOST OF THE TIME…

0

1

2

3

4

5

6

7

8

9

10

 

 4

SELF-CENTERED OR STUCK UP…

0

1

2

3

4

5

6

7

8

9

10

 

 5

POOR PERSONAL APPEARANCE…

0

1

2

3

4

5

6

7

8

9

10

 

 6

WASTES TIME

0

1

2

3

4

5

6

7

8

9

10

 

 7

OTHERS TAKE ADVANTAGE OF CHILD

0

1

2

3

4

5

6

7

8

9

10

 

 8

SHY OR TOO QUIET

0

1

2

3

4

5

6

7

8

9

10

 

 9

IMMODEST ABOUT BODY, SHOWS OFF

0

1

2

3

4

5

6

7

8

9

10

 

10

SETS GOALS TOO HIGH

0

1

2

3

4

5

6

7

8

9

10

 

11

DENIES HAVING DONE WRONG

0

1

2

3

4

5

6

7

8

9

10

 

12

TELLS THINGS THAT DID NOT OCCUR

0

1

2

3

4

5

6

7

8

9

10

 

13

CLINGS TO ADULTS

0

1

2

3

4

5

6

7

8

9

10

 

14

RESTLESS SLEEP

0

1

2

3

4

5

6

7

8

9

10

 

15

HAS TROUBLE FALLING ASLEEP…

0

1

2

3

4

5

6

7

8

9

10

 

16

CRIES OFTEN

0

1

2

3

4

5

6

7

8

9

10

 

17

SOILS SELF OR CLOTHING (URINATION OR BOWEL)

0

1

2

3

4

5

6

7

8

9

10

 

18

WETS THE BED

0

1

2

3

4

5

6

7

8

9

10

 

19

ACTS OLDER THAN ACTUAL AGE

0

1

2

3

4

5

6

7

8

9

10

 

20

RESTLESS, OVERACTIVE…

0

1

2

3

4

5

6

7

8

9

10

 

21

FEELINGS HURT EASILY…

0

1

2

3

4

5

6

7

8

9

10

 

22

ACTS YOUNGER THAN ACTUAL AGE

0

1

2

3

4

5

6

7

8

9

10

 

23

POOR SELF-IMAGE

0

1

2

3

4

5

6

7

8

9

10

 

24

TAKES CORRECTION POORLY

0

1

2

3

4

5

6

7

8

9

10

 

25

BLAMES OTHERS FOR MISTAKES…

0

1

2

3

4

5

6

7

8

9

10

 

26

BAD RELATIONS WITH ADULTS…

0

1

2

3

4

5

6

7

8

9

10

 

27

HAS DEPRESSED ATTITUDE…

0

1

2

3

4

5

6

7

8

9

10

 

28

HAS FREQUENT HEADACHES

0

1

2

3

4

5

6

7

8

9

10

 

29

COMPLAINS OF ACHES AND PAINS…

0

1

2

3

4

5

6

7

8

9

10

 

30

FEELS DEPRESSED A LOT

0

1

2

3

4

5

6

7

8

9

10

 

31

MAKES POOR GRADES IN SCHOOL

0

1

2

3

4

5

6

7

8

9

10

 

32

FIGHTS AT SCHOOL…

0

1

2

3

4

5

6

7

8

9

10

 

33

DISCIPLINE PROBLEM AT SCHOOL…

0

1

2

3

4

5

6

7

8

9

10

 

34

DOES NOT COMPLETE HOMEWORK…

0

1

2

3

4

5

6

7

8

9

10

 

35

STEALS AT SCHOOL…

0

1

2

3

4

5

6

7

8

9

10

 

36

GETS ANGRY EASILY…

0

1

2

3

4

5

6

7

8

9

10

 

37

KEEPS ANGER TO SELF

0

1

2

3

4

5

6

7

8

9

10

 

38

DOES AS HE/ SHE PLEASES

0

1

2

3

4

5

6

7

8

9

10

 

39

STEALS FROM STORES, ETC…

0

1

2

3

4

5

6

7

8

9

10

 

40

BAD RELATIONSHIP WITH OTHER KIDS

0

1

2

3

4

5

6

7

8

9

10

 

41

HAS EXPLOSIVE TEMPER TANTRUMS

0

1

2

3

4

5

6

7

8

9

10

 

42

BULLIES OTHER CHILDREN

0

1

2

3

4

5

6

7

8

9

10

 

43

STEALS AT HOME

0

1

2

3

4

5

6

7

8

9

10

 

44

USES PROFANITY

0

1

2

3

4

5

6

7

8

9

10

 

45

ABUSES OBJECTS (FURNITURE, ETC.)

0

1

2

3

4

5

6

7

8

9

10

 

46

INAPPROPRIATE SEXUAL BEHAVIOR

0

1

2

3

4

5

6

7

8

9

10

 

47

USES TOBACCO (SMOKES, CHEW, ETC.)

0

1

2

3

4

5

6

7

8

9

10

 

48

USES ALCOHOLIC BEVERAGES

0

1

2

3

4

5

6

7

8

9

10

 

49

USES DRUGS (SPECITY_____________________

0

1

2

3

4

5

6

7

8

9

10

 

50

GANG INVOLVEMENT/ INTEREST

0

1

2

3

4

5

6

7

8

9

10

 

51

LACK OF PARENTAL SUPERVISION

0

1

2

3

4

5

6

7

8

9

10

 

52

NEGLECT

0

1

2

3

4

5

6

7

8

9

10

 

53

LACK OF ECONOMIC RESOURCES

0

1

2

3

4

5

6

7

8

9

10

 

54

EASILY DISTRACTED

0

1

2

3

4

5

6

7

8

9

10

 

55

LIKES SCHOOL

0

1

2

3

4

5

6

7

8

9

10

 

56

EXHIBITS LEADERSHIP QUALITIES

0

1

2

3

4

5

6

7

8

9

10

 

57

RESPONSIBLE, FOLLOWS RULES….

0

1

2

3

4

5

6

7

8

9

10

 

58

CONSIDERATE, HELPFUL…

0

1

2

3

4

5

6

7

8

9

10

 

59

AFFECTIONATE…

0

1

2

3

4

5

6

7

8

9

10

 

60

HAPPY GO LUCKY, PLAYFUL

0

1

2

3

4

5

6

7

8

9

10

 

61

ENTERTAINS SELF WELL

0

1

2

3

4

5

6

7

8

9

10

 

62

SAD/CRIES

0

1

2

3

4

5

6

7

8

9

10

 

63

FEELS USELESS, HELPLESS

0

1

2

3

4

5

6

7

8

9

10

 

64

SULKS AND POUTS…

0

1

2

3

4

5

6

7

8

9

10

 

 65

WITHDRAWN/PERFERS BEING ALONE

0

1

2

3

4

5

6

7

8

9

10

 

 66

MOODY/EMOTION SHIFT QUICKLY

0

1

2

3

4

5

6

7

8

9

10

 

 67

NERVOUS, FEARFUL, ANXIOUS

0

1

2

3

4

5

6

7

8

9

10

 

 68

TOUCHY, RESENTS CRITICISM

0

1

2

3

4

5

6

7

8

9

10

 

 69

SHOW EMOTION

0

1

2

3

4

5

6

7

8

9

10

 

70

BITES NAILS

0

1

2

3

4

5

6

7

8

9

10

 

71

GIVES UP EASILY

0

1

2

3

4

5

6

7

8

9

10

 

72

ARGUES, CRITICIZES OTHERS

0

1

2

3

4

5

6

7

8

9

10

 

73

CURSES, USE ABUSIVE LANGUAGE

0

1

2

3

4

5

6

7

8

9

10

 

74

CONS OTHERS/MANIPULATIVE…

0

1

2

3

4

5

6

7

8

9

10

 

75

DEMANDS ATTENTION…

0

1

2

3

4

5

6

7

8

9

10

 

76

RESENTS DISCIPLINE…

0

1

2

3

4

5

6

7

8

9

10

 

77

SCRATCHES, CUTS OR HURTS SELF…

0

1

2

3

4

5

6

7

8

9

10

 

78

PLAYS WITH FIRE/ MATCHES…

0

1

2

3

4

5

6

7

8

9

10

 

79

DISTORTS THE TRUTH

0

1

2

3

4

5

6

7

8

9

10

 

80

CONFUSED, RAMBLED SPEECH

0

1

2

3

4

5

6

7

8

9

10

 

81

“BORROWS” WITHOUT PERMISSION

0

1

2

3

4

5

6

7

8

9

10

 

82

MAKES UNUSUAL REPETITIVE MOVEMENTS

0

1

2

3

4

5

6

7

8

9

10

 

83

NERVOUS HABITS (SPECIFY_____________________)

0

1

2

3

4

5

6

7

8

9

10

 

84

HITS, FIGHTS, ATTACKS OTHERS

0

1

2

3

4

5

6

7

8

9

10

 

85

THREATENS TO HURT OTHERS

0

1

2

3

4

5

6

7

8

9

10

 

86

MAKES FRIENDS EASILY

0

1

2

3

4

5

6

7

8

9

10

 

87

PASSIVE, EASILY INFLUENCED…

0

1

2

3

4

5

6

7

8

9

10

 

88

WILLING TO SHARE WITH OTHERS

0

1

2

3

4

5

6

7

8

9

10

 

89

DEFENDS SELF

0

1

2

3

4

5

6

7

8

9

10

 

90

FORMS CLOSE RELATIONSHIPS

0

1

2

3

4

5

6

7

8

9

10

 

 

91

VANDALIZES, DESTROYS OBJECTS

0

1

2

3

4

5

6

7

8

9

10

92

USES WEAPONS (SPECIFY______________________)

0

1

2

3

4

5

6

7

8

9

10

93

RUNS AWAY (#_______)…………………………

0

1

2

3

4

5

6

7

8

9

10

94

SNIFFS PAINTS, SOLVENTS, GASOLINE, ETC…

0

1

2

3

4

5

6

7

8

9

10

95

SMOKES MARIJUANA

0

1

2

3

4

5

6

7

8

9

10

96

DEALS DRUGS…

0

1

2

3

4

5

6

7

8

9

10

97

FORGERY/ THEFT BY CHECK

0

1

2

3

4

5

6

7

8

9

10

98

AUTOMOBILE THEFT

0

1

2

3

4

5

6

7

8

9

10

99

IMPULSIVE…

0

1

2

3

4

5

6

7

8

9

10

100

HAPPY TO COME TO THE TIPTON HOME

0

1

2

3

4

5

6

7

8

9

10

 

EXPECTATION/ NEED ASSESSMENT

 

WHAT ARE YOUR EXPECTATIONS OF THE TIPTON HOME? ______________________________

 

_____________________________________________________________________________________

 

_____________________________________________________________________________________

 

_____________________________________________________________________________________

 

_____________________________________________________________________________________

 

WHAT AREAS DOES THE CHILD NEED HELP WITH? _____________________________________

 

_____________________________________________________________________________________

 

_____________________________________________________________________________________

 

_____________________________________________________________________________________

IF FOR SOME REASON THE CHILD CANNOT STAY AT THE TIPTON HOME PAST THE 30-DAY TRIAL

PERIOD OR LATER, WHO WILL COME TO PICK UP THE CHILD?

 

NAME_______________________________________________________________________________

 

ADDRESS____________________________________________________________________________

 

HOME PHONE #_________________________CELL PHONE # _______________________________

 

PAGER #_____________________________WORK PHONE # ________________________________

 

A FRIEND’S #___________________________A NEIGHBOR’S #______________________________

 

EMAIL ADDRESS_____________________________________________________________________

 

                                     I HEREBY CONFIRM THAT THE ABOVE STATEMENTS ARE

                            TRUE TO THE BEST OF MY ABILITY.

 

 

                            ______________________________________________________________________

                                 SIGNATURE OF GUARDIAN                                                                                DATE

 

 

 

                           _______________________________________________________________________

                                 SIGNATURE OF CHILD                                                                                         DATE

 

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