Toll-Free 866-635-7102
P. 405-701-8530 F. 405-701-8531
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
Has the child or anyone in the household traveled internationally within the last 14 days? YesNoI don't know Please describe recent travel.
Does the child have signs or symptoms of a respiratory infection, such as a fever, cough, or sore throat? YesNoI don't know Please describe signs or symptoms.
Has the child had contact with someone with or under investigation for COVID-19? YesNoI don't know Please describe contact.
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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