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):
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
Substance use YesNo
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)?
Incontinence of bowel/bladder (bedwetting, etc.)?
Vision or hearing issues?
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?