Online Screening

Child's name (required)

Child's date of birth (required)

Parent/Guardian's first & last name

Phone number (required)

If the child is in DHS or OJA custody, please check one of the following (if neither, leave blank):
DHSOJA
Case worker's first & last name (if applicable)

Child's street address

Child's city of residence

Child's state of residence

Child's zip code

Child's gender (required)

Child's height (required)

Child's weight (required)

What are the main behavioral issues/concerns that you are having with your child? Please explain. (response required)

Has your child displayed any of these behaviors within the last 2 weeks? If yes, please provide approximate dates.
Suicidal threats/gestures YesNo
Dates:
Self-harm YesNo
Dates:
Aggression YesNo
Dates:
Substance use YesNo
Dates:

Does the child have any legal issues (probation, pending charges, arrests, etc.)?
YesNoI don't know
Please describe legal issues. If none, type "none".

If your child has had inpatient treatment before (acute hospital, crisis, or residential), or is currently in an inpatient hospital or facility, please list when and where your child received treatment. If none, type "none".

If your child has had outpatient treatment before, or is currently receiving outpatient services, please list when and where your child received treatment. If none, type "none".

Has the child ever been diagnosed with any learning disabilities (developmental delay, autism, etc.)?
YesNoI don't know
What is the child's IQ? (if available)

Does the child have any of the following medical issues (currently or previously)?

Heart disease?
YesNo

Digestive disease?
YesNo

Lung/respiratory disease?
YesNo

Seizures?
YesNo

Incontinence of bowel/bladder (bedwetting, etc.)?
YesNo

Dental problems?
YesNo

Vision or hearing issues?
YesNo

Diabetes?
YesNo

List current medications (dosage/frequency):

Your (submitter's) first & last name: (required)

Your (submitter's) relationship to the child: (required)

Your (submitter's) email address:

Your (submitter's) phone number:

How did you hear about Red River Youth Academy?