United Methodist Childrens Home: Services: Residential: Admissions Form

Residential › Admissions Form

For admission consideration or further information, contact: Tim Waugh at
(618) 242-1070 x228 or timw@umchome.org.

First Name
Middle Name
Last Name
Age
Birth Date
Sex
Address:
Street
City
State
Zip
Family:
Mother
Address
Phone
Father
Address
Phone
Current Status of Parents Relationship:
Current Guardian
Parental Rights Intact:
Mother
Father
Names, Address, Telephone
Siblings:
Name #1
Age
In Home
Name #2
Age
In Home
Name #3
Age
In Home
Name #4
Age
In Home
Name #5
Age
In Home
Name #6
Age
In Home
Other Important Sources of Support
Payment Information:
Is this youth covered by Illinois Department of Public Aid Medicaid?
Medicaid Case ID #
Medicaid ID #
Are they a ward of the Illinois Department of Children and Family Services?
Case Worker
Phone
Is youth covered by private insurance that pays for residental treatment?
Insurance Company
Insurance Phone
Insurance Name
Relationship to Youth
Group ID
Is youth being placed by a school district through IL Board of Education?
School District
Contact Person
Phone Number
Is youth eligible for Individual Care Grant (ICG) through the Illinois Department of Mental Health? (If unsure, call 1-800-843-6154)
Is youth being placed by The Illinois Department of Corrections or their local probation department?
Probation Department
Contact Person
Phone Number
School Information:
Current Grade in School
Last School Attended
Average Grades
Best Way of Learning
Favorite Subject
Does this youth receive special education assistance?
If yes, what type of assistance?
Medical Information:
Current Physician
Phone
Current Medications
Past Hospitalizations or Surgeries
Medical Difficulties
Allergies
Full Term Pregnancy
Complications
Age That Youth Walked
Age Youth Talked
Age Youth Had Bowel and Bladder Control
Psychiatric History:
Previous Mental Health Treatment Hospitalizations
Psychiatrist
Phone
Therapist
Phone
Current Treatment:
Hospitalizations
Psychiatrist
Therapist
Current Medications
Current Diagnosis
Has the youth ever been physically / emotionally or sexually abused?
If Yes, Explain
Is there a history of domestic violence in the family?
If Yes, Explain
Is there a history of alcohol or drug abuse in the family?
If Yes, Explain
Have any other family members ever been treated for mental illness or mood problems?
If Yes, Explain
What does youth do for fun?
How does he or she get along with other adults and children?
Other agency involvement or services being offered: