Child's name (required)
Child's date of birth (required)
Parent/Guardian's first & last name (required)
Is the child in court appointed custody?
If yes, through which agency is the child in custody?
Child's city of residence (required)
Insurance provider (required)
List any current medications (dosage/frequency)
Any history of heart disease?
Any history of digestive disease?
Any history of lung/respiratory disease?
Any history of seizures?
Any history of incontinence of bowel/bladder (bedwetting, etc.)?
Any major dental problems?
Any vision or hearing problems?
Does your child have diabetes?
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?
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)
Okay to leave a message on your cell phone?
Okay to leave a message at this number?