Screening Information

    Applying for Admission into:
    Volusia Cty ResidentialMadison Cty ResidentialSpecialized Therapeutic Home

    Child’s Full Name: *

    Nickname:

    Age:

    Current Grade:

    Date of Birth:

    Child’s Social Security Number :

    Color Eyes :

    Color Hair :

    Place of Birth

    City:

    County:

    State:

    Race:

    Ethnicity:

    Religion:

    Custodial:
    Primary Residential ParentOther Custodial

    Explain:

    Guardian Name/s: *

    Home Phone:

    Work Phone:

    Cell Phone:

    Email Address: *

    Street Address:

    City:

    State:

    Zip:

    County:

    I give permission to the staff of the Florida United Methodist Children’s Home to leave a telephone message at the following telephone numbers and/or email (check all that apply):
    HomeCellWorkEmail
    Referred By:

    Name: *

    Church/Agency:

    Address:

    City:

    State:

    Zip:

    Telephone:

    Health Insurance Information:

    Health Insurance Provider:

    Medicaid #:

    Policy #:

    Type of Coverage:

    Primary Physician:

    Address:

    Telephone:

    Medical Information:

    Does child have any known allergies or sensitivities?

    Has child ever been hospitalized?:
    yesno

    Age:

    How Long:

    Reason

    Medication History:

    Date:

    Medication:

    Prescribing Physician:

    Response to Medication

    Has the child ever been seen by a medical specialist for a major illness or accident?
    yesno

    Age:

    How Long:

    Reason

    FAMILY/GUARDIAN INFORMATION

    Mother's Name:

    Mother's Occupation:

    Mother's Level of Education:

    Father's Name:

    Father's Occupation:

    Father's Level of Education:

    Other Guardian's Name:

    Other Guardian's Occupation:

    Other Guardian's Level of Education:

    Are the parents divorced/separated?
    yesno

    If yes, explain

    Does the parent/guardian experience any health problems or disabilities?
    yesno

    If yes, explain

    Has the parent/guardian ever been treated for mental health related issues?
    yesno

    Age:

    How Long:

    Reason

    Who else lives in the home?

    Name:

    Age:

    Name:

    Age:

    Name:

    Age:

    Name:

    Age:

    IF CHILD IS ADOPTED

    Age of child at the time of adoption:

    Relevant information about biological parents (substance abuse/mental health/medical history)

    Type of adoption:

    Relevant pre-adoption history (abuse, neglect etc.):

    PRESENTING PROBLEM

    Briefly Describe your concerns:

    TREATMENT HISTORY
    Previous Counseling

    When:

    Where:

    Therapist/Title:

    Response To:

    Has the child ever attempted to commit suicide or expressed a wish to die?
    yesno

    Age:

    Reason

    Has the child ever attempted or expressed the wish to harm others?
    yesno

    If yes, Explain

    Has the child ever been in residential care?
    yesno

    Age:

    How Long:

    Reason

    Has the child ever experienced, witnessed or been exposed to any of the following?
    Sexual AbusePhysical AbuseNeglectDomestic ViolenceCar Accident other AccidentPremature BirthMajor Medical ProcedureDivorceAdoption/Foster CareChange of primary caretakerSeparation/Loss
    SUBSTANCE ABUSE HISTORY

    Any family history of substance/alcohol abuse (including grand-parents, relatives)?

    Parent/guardian history of substance/alcohol abuse (including step-parents, co-caretakers)?

    Child’s history of substance/alcohol abuse and or cigarette smoking?

    LEGAL HISTORY
    Has the child ever had difficulty with the police?
    yesno
    Has the child ever been on probation?
    yesno
    Has the child ever appeared in juvenile court?
    yesno

    Comments:

    Has the family ever been involved with DCF/CPC?
    yesno

    When:

    Reason

    Is there currently an open case/investigation?
    yesno
    Has the child ever been in foster care or DCF/CPC custody?
    yesno

    Age:

    How Long:

    Reason

    ACADEMIC HISTORY

    School the child is presently attending:

    School Address:

    School Phone:

    County:

    Current grade placement:

    What are the child’s typical grades? :

    Does the child receive Special Education (ESE) services?
    yesno
    If you answered yes, please provide a copy of the IEP
    Does the child have behavior problems in school?
    yesno

    Explain

    Does the child skip or cut classes?
    yesno

    How often

    Has the child ever failed or been held back?
    yesno

    What grades

    Has the child ever been suspended or expelled to an alternative school?
    yesno

    If yes, Reason

    BEHAVIORAL CONCERNS
    Does the child display any of the following behaviors?
    Defiance/Does not follow rulesLyingStealingTalks BackUncontrollable Anger/RageVerbal AggressionDestruction of PropertyPhysical Aggression with PeoplePhysical Aggression/Cruelty toward AnimalsFire SettingInterruptsDaydreamsLacks focus/concentrationOften forgetfulCannot sit still/excessive fidgetingWorries frequentlyAppears nervousAppears sadOften moodyOften withdrawsAppears shySees/hears things that others don’t
    Does the child display Sexual Promiscuity/Sexually active behaviour?
    yesno

    If yes, How many partners

    Does the child display Sexually inappropriate/offending behaviors?
    yesno

    If yes, Explain

    Does the child Runs away from home?
    yesno

    If yes, How many times/how often?

    Does the child has Excessive dieting behaviors?
    yesno

    If yes, How often?

    Does the child display Binging/Purging behaviors?
    yesno

    If yes, How often?

    Does the child display Abuse of diet pills/laxatives behaviors?
    yesno

    If yes, Frequency/Amount?

    Does the child display Self-Injurious behaviors?
    yesno

    If yes, Frequency/Severity of Injury?

    Does the child violate physical boundaries of others?
    yesno

    If yes, How?

    Does the child violates emotional boundaries of others?
    yesno

    If yes, How?

    Does the child has difficulty making or keeping friends?
    yesno

    If yes, How so?

    How does the child behave in the home?

    How does the child express anger/frustration?

    How does the child express sadness?

    How does the parent/guardian discipline the child?

    What are the child’s strengths and interests?

    Comments