Assessment and Admission Form
Please submit this form and attachments for review by the Executive Office before any child is admitted to Asia’s Hope’s care or before any promise of admission has been given. Please direct questions about this process to jeremiah@asiashope.org or a member of the Executive Office staff.
Name of person completing this assessment
First Name
Last Name
Position/title:
Your email:
example@example.com
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About the referral
Information about the sources of information used in this assessment
Date of receiving information about this child or staff
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date of referral
Source of referral
Government ministry/department
Hospital
Police
Court/Justice system
NGO
Identified on the street
Drop-in center
Hotline
Self-referral/Walk-in
Family
Friend
Local government or village authority
Other
Any other important information about this referral
Proposed date of admission to Asia's Hope
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
The date that the child will come to Asia's Hope, if admitted
Proposed Home
Battambang 1
Battambang 2
Battambang 3
Battambang 4
Battambang 5
Battambang 6
Battambang 7
Battambang 8
Battambang 9
Battambang 10
Battambang 11
Battambang 12
Battambang 13
Prek Eng 1
Prek Eng 2
Prek Eng 3
Prek Eng 4
Prek Eng 5
Prek Eng 6
Kalimpong 1
Kalimpong 2
Kalimpong 3
Kalimpong 4
Kalimpong 5
Kalimpong 6
Doi Saket 1a
Doi Saket 1b
Doi Saket 1c
Doi Saket 1d
Doi Saket 2
Doi Saket 3
Soi Saket 4
Wiang Pa Pao 1
Wiang Pa Pao 2
Wiang Pa Pao 3
Indicate the Home that the child will be placed in, if they are admitted
Type of admission
Temporary
Provisional
Permanent
Asia's Hope Staff
Asia's Hope Staff Child
Describe the reasons why the child is in need of Asia’s Hope’s care/Bio of child or staff:
Assessors opinion about child's need for care
Scan and attach official assessment or case documents from government agency or third party referral source.
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About the child or staff
Basic information
Full legal name
First Name
Middle Name
Last Name
Other names or nicknames
Full Name in native language/script
First Name
Last Name
Sex
Female
Male
Other
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Religion
Tribe, caste, or ethic group
Current address
Street Address
Street Address Line 2 or Landmark
City
State / Province
Postal / Zip Code
Is the child a citizen?
Yes
No
Government ID number
Of what country(ies) are they a citizen?
Attach (1) a current picture of the child and (2) a current picture the child and their current caregivers in front of their place of residence.
*
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About the child or staff
Education
Current grade level, or if the child is illiterate/unschooled
Name and contact information of current school
Difficulties in school
Failure in the class last studied
Lack of interest in the school activities
Indifferent attitude of the teachers
Negative peer group influence
Bullying in school
Absenteeism or running away from school
There is no appropriate level of school nearby
Abuse in school
Corporal punishment
Learning disability
Suspected learning disability
Absenteeism due to child working to support family
No known difficulties in school
Other
Languages spoken by the child
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About the child
Mental, physical condition, and adverse experience(s)
Health history of child
Rows
Present
Absent
Not known
Respiratory disorders
Hearing impairment
Eye diseases
Dental disease
Cardiac diseases
Skin disease
Sexually transmitted diseases
Neurological disorders
Mental handicap
Physical handicap
Urinary tract infections
HIV/AIDS
Others (pl. specify)
Other health issues
Is the child is differently abeld
Hearing Impairment
Speech Impairment
Physically disabled
Mentally disabled
No known impairment or disability
Other
Habits of the child
Smoking
Drinking
Drug or substance abuse
Gambling
Begging
Other
No known habits
Habit's of the child, Other
Does the child have any addiction(s)?
Yes
No
What is their addiction?
Is the child the victim of abuse or any offense?
Emotional/verbal abuse
Physical abuse
Sexual abuse
No known abuse
Other
Details of abuse
Lack of access to basic necessities
Lack of food and water
Lack of shelter
Lack of adult supervision
Lack of clothes
Lack of education
Lack of psychological support
Other
Issues and needs
Abuse by parent(s)/caregiver(s)
Death of parents
Abandonment
Incapacitation of parents
Criminal behavior of parents
Separation/divorce of parents
Witnessing domestic violence
Child migration
Child of migrating family
Neglect
Negative peer group influence
Street-living
Forced marriage
Child in conflict with the law
Other
Extra-curricular activities and hobbies of the child:
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About the child
Family information
For each immediate family member or caregiver prior to coming to Asia's Hope, provide the following information.
Rows
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
Person 7
Full name
Relationship to child
Age
Sex
Education
Occupation/employment
Income
Health Status
History of mental illness or impairment
History of addiction
Contact number
Address
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Sign and submit
You will receive confirmation from the Executive Office that your submission was received within 24 hours. If you do not receive confirmation within that time period, please contact the Executive Office immediately.
Do you have any concerns or questions about the accuracy of the information you were given about this child? If yes, please describe.
To the best of my knowledge, I certify that the contents of this assessment are true and accurate.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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