Online Screening

Child's name (required)

Child's date of birth (required)

Parent/Guardian's first & last name (required)

Is the child in court appointed custody?
YesNo
If yes, through which agency is the child in custody?
DHSOJATribal

Child's city of residence (required)

Insurance provider (required)

List any current medications (dosage/frequency)

Any history of heart disease?
YesNo

Any history of digestive disease?
YesNo

Any history of lung/respiratory disease?
YesNo

Any history of seizures?
YesNo

Any history of incontinence of bowel/bladder (bedwetting, etc.)?
YesNo

Any major dental problems?
YesNo

Any vision or hearing problems?
YesNo

Does your child have diabetes?
YesNo
If yes, what type? Insulin dependent or taking medication?

Please describe any other medical conditions.

What are the main behavioral issues and concerns that you are having with your child? Please explain.

Has your child displayed these behaviors within the last 2 weeks?
YesNo

If your child is currently receiving outpatient mental health services, please list the contact information for the counselor or agency where he/she is receiving therapy, and how long the child has been receiving services.

If your child is not currently receiving outpatient mental health services, but has in the past, please list the contact information for the counselor(s) or agency where he/she received services, and when the child received services.

If your child has had inpatient treatment before (acute, crisis, or residential), or is currently in an inpatient hospital or facility, please list when and where your child received treatment.

Does the child have any legal issues (probation, pending charges, arrests, etc.)?
YesNoI don't know
Please describe legal issues.

Describe any substance abuse issues (type, frequency, history).

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

How did you hear about Red River Youth Academy?

Your (submitter's) first & last name

Your (submitter's) email address

Your (submitter's) relationship to the child

How may we contact you? (enter your preferred contact methods below)
Cell Phone
Okay to leave a message on your cell phone?
YesNo

Other Phone
Okay to leave a message at this number?
YesNo

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