TARA HALL HOME FOR BOYS APPLICATION

TARA HALL HOME FOR BOYS

James E. Dumm, Jr. | Director
P.O. BOX 955, GEORGETOWN, SC 29442 | (843) 546-3000 | fax (843) 527-2156
APPLICANT INFORMATION
In order to adequately consider a youth for placement, we will need the following information:
1. The Application
2. Copy of the Court Order establishing custody of the youth. (only if court action has occurred)
3. Results of recent psychological testing.
4. School Records (attendance, grades, recent testing & behavior)
5. Any - All behavioral health a ssessments
If the youth is accepted into our program we will need the following information at admission time.
1. Copy of current physical exam (within 6 months)
2. Copy of immunization record
3. Copy of Birth Certificate
4. Copy of Social Security Card
5. Insurance and/or Medicaid Card
This information will greatly help us in planning when considering a youth’s application.

Thank you for your cooperation!

PF-15F
TARA HALL HOME FOR BOYS BASIC INFORMATION FORM
Today's Date

Month Day Year
Date
Referred by
Child's Name
Child's Date of Birth

Month Day Year
Date
Child's Place of Birth

Child's Address

Street Address
Street Address 2
City	State / Province
Postal / Zip Code	Country

County
Phone Number

Area Code Phone Number
Present Parental Structure (please check ONE)

Natural Mother & Father Natural Mother & Step Father Natural Father & Step Mother Mother & Boyfriend Father & Girlfriend Mother Only Father Only Foster Parents Parents by Adoption Other (If other, please describe below:)
Other
Insurance Information
Insurance Company
Company Name and Number
Medicaid
Medicaid Number
Legal Custody
Name and Phone Number
Emergency Contact
Name and Phone Number
Child's Family Doctor:
FAMILY INFORMATION
Natural Mother's Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Mother's Date of Birth
Mother's Marital Status
Mother's Education
Relationship with Child (good, strained, etc.)
Willing to Participate in Program?
Agrees to a Visitation Schedule?
Step Father's/Live-in Partner's Name
Natural Father's Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Father's Date of Birth
Father's Marital Status
Father's Education
Relationship with Child (good, strained, etc.)
Willing to Participate in Program?
Willing to Participate in Family Counseling?
Step Mother's/Live-in Partner's Name
Child's Siblings
Sibling 1:
Name and Date of Birth
Sibling 2:
Name and Date of Birth
Sibling 3:
Name and Date of Birth
Sibling 4:
Name and Date of Birth
Maternal Grandmother's Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
Relationship with Child (good, strained, etc.)
Maternal Grandfather's Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
Relationship with Child (good, strained, etc.)
Paternal Grandmother's Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
Relationship with Child (good, strained, etc.)
Paternal Grandfather's Name

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
Relationship with Child (good, strained, etc.)
If a Step Parent is present: Relationship with Child (good, strained, etc.)
CHILD’S INFORMATION
Legal Name
Last Name, First Name Middle
Nickname
Age
Sex
Race
Height
Weight
Religion
With whom is the child living?
How long has the child lived at this address?
Who has legal custody of the child?
Where has the youth lived within the past 5 years?
Residence 1 (most recent)
Location (address if possible), Date Range, Reason for Moving
Residence 2
Location (address if possible), Date Range, Reason for Moving
Residence 3
Location (address if possible), Date Range, Reason for Moving
List any people currently living in home with the child:
Such as uncles, cousins, friends, etc.
Describe any major problems within the family which limits their ability to be effective with the child. (such as alcoholism, drug abuse, mental illness, mental retardation, child abuse/neglect, etc.)
SCHOOL INFORMATION
Present School
Grade

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
Contact Person
Does the child attend any special classes? Please describe.
Does the child have any learning disabilities? Please describe.
List areas of academic strengths and weaknesses.
List suspensions from school.
Include Dates and Reasons for Suspensions
Has the child ever struck a teacher or school administrator?

Yes No
Describe relationships the child to school personnel. List any specific teachers/officials with whom the child has a noticeably good or poor relationship.
List grades the child has repeated, if any.
Reason for retention
CHILD’S PERSONALITY & BEHAVIOR

How well does the child relate to others his age?

	1	2	3	4	5

1 is Not Well At All, 5 is Very Well

How well does the child establish and maintain friendships?

	1	2	3	4	5

1 is Not Well At All, 5 is Very Well

Does the child prefer to play by himself or with his peers?
Is the child prone to temper outbursts?

Yes No
If YES, please explain.
Is the child prone to lying or dishonesty?

Yes No
If YES, specify any ‘cues’ that might indicate such (voice tone, facial expression, etc.)
In your opinion, is the child excessively introverted or extroverted? Please explain.
Briefly describe what you consider to be the child’s personality strengths and weaknesses.
What special talents, aptitudes, hobbies or interests does the child have?
JUVENILE COURT SYSTEM INVOLVEMENT
List below any contacts with the court system.
Contacts with Court System
Include offense/charge, date and disposition.
Is the child currently on probation?

Yes No
If YES, please explain.
Include what for, how long, and the conditions of the probation.
How many times has the child run away in the past year?
How many times has the child THREATENED to run away in the past?
Has the child ever been involved in propose destruction of property?

Yes No
If YES, please explain.
How many fights has the child been involved in the past year?
If involved in a fight(s), please explain.
Has the child ever used a weapon to threaten or harm someone else?

Yes No
If YES, please explain.
MEDICAL HISTORY
Please check any of the following that apply to the child.

Fainting or Dizziness Hyperactivity Phobias Trouble Sleeping Sleepwalking Nightmares Talking in Sleep Unusual Eating Habits Eating Non-Food Excessive Poor Hygiene Encopresis Enuresis Exposing Genitals Prolonged Refusal to Speak Stuttering or Other Speech Problems Threatened Suicide Attempted Suicide Been Cruel to Animals or Other Children
If ANY of the above apply, please explain.
Has the child ever had any accidents, injuries, or operations?

Yes No
If YES, please explain.
Is the child currently using any medication?

Yes No
If YES, please explain.
Is the child allergic to any type of medication?

Yes No
If YES, please explain.
Is the child allergic to any type of food?

Yes No
If YES, please explain.
Does the child wear eyeglasses?

Yes No
Name of Eye Doctor
Has the child ever been on medication for behavioral or emotional difficulties? (hyperactivity, depression, etc.)

Yes No
If YES, please explain.
Has the child been involved with drugs or alcohol ?

Yes No
If YES, please explain.
Include frequency, circumstances, etc.
Is there any medical reason why the child should not participate in sports or other outdoor activities?
Please check any medical conditions the CHILD has had or has now.

Allergies (describe below) Chickenpox Diphtheria Discharging Ears Eye problems Frequesnt Colds German Measles Influenza Cystic Fibrosis Measles Loss of Bowel Control Polio Pneumonia Rheumatic Fever Scarlet Fever Orthopedic Problems Tuberculosis Tonsilitis Diabetes Abnormal Fears Asthma Whooping Cough Dental Needs Venereal disease Epilepsy Lung Disease Heart problems Kidney Disorders Smallpox
If ANY medical conditions above apply, please explain (including description of allergies).
Please explain any medical condition or problem which has not been indicated above.
Please check if there is a FAMILY HISTORY of any of these medical conditions.

Allergies (describe below) Chickenpox Diphtheria Discharging Ears Eye problems Frequesnt Colds German Measles Influenza Cystic Fibrosis Measles Loss of Bowel Control Polio Pneumonia Rheumatic Fever Scarlet Fever Orthopedic Problems Tuberculosis Tonsilitis Diabetes Abnormal Fears Asthma Whooping Cough Dental Needs Venereal disease Epilepsy Lung Disease Heart problems Kidney Disorders Smallpox
If a family history exists, please explain (including description of allergies).
Name of Family Doctor

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number

Area Code Phone Number
PRE-NATAL & BIRTH INFORMATION
Was pregnancy full term?

Yes No
If NO, please describe.
Birth Weight of Child
Were there any complications during pregnancy or during birth?

Yes No
If YES, please describe.
Was birth normal or Cesarean?

Normal Cesarean
Did birth mother use alcohol or drugs during pregnancy?

Yes No
If YES, please describe.
Describe 1st year of life as far as reaching milestones (such as sitting up, crawling, potty training, etc.)
REFERRAL & TREATMENT
Length of time the referral agent has been directly involved with the child.
What incident or legal offense prompted this application? (type of petition, school problems, running away, vandalism, probation violation, etc.)
Why is the child being referred? (general summary of problems)
Please list other professionals with whom the child has been involved in regard to his problems.
Include names, addresses and dates of involvement.
Please explain if the child is currently involved with any other helping professional or agency.
Referral Agent
Other than Tara Hall, what programs or forms of treatment may be utilized to help the child with his problems?
Will the child have the availability of spending visiting weekends and holidays in his home while placed at the group home?

Yes No
Will the child have the availability of returning to his home after completion of the program?

Yes No
If NO, what are the long-range plans for this child?
What role do you see Tara Hall playing in these plans?
If the child is accepted, what do you expect from our programs?
Is there anything that we should know that is not covered on this application?
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TARA HALL HOME FOR BOYS

APPLICANT INFORMATION

TARA HALL HOME FOR BOYS BASIC INFORMATION FORM

FAMILY INFORMATION

CHILD’S INFORMATION

SCHOOL INFORMATION

CHILD’S PERSONALITY & BEHAVIOR

JUVENILE COURT SYSTEM INVOLVEMENT

MEDICAL HISTORY

PRE-NATAL & BIRTH INFORMATION

REFERRAL & TREATMENT