Application Form

Application Form
As you complete the application you will be asked for the following information below. Please provide the requested information, if applicable, to the best of your ability however, if you do not have any of the requested information at the time of your completing this application you can still complete and submit the application for review and provide the requested information at a later time.
- A separate picture of both the front and back of your medical insurance card
- A copy of the current custody agreement
- Psychological evaluations/biopsychosocial records
- Any medical records, testing, and/or evaluations
- Most up to date immunization records
- A separate picture of both the front and back of your dental insurance card
- Any education evaluations if applicable
- IEP or 504 Plan if applicable
Please use the SAVE button below to send a link to your email to continue the form later. Use the NEXT button to progress through the application form.
Patient/Student Information
Patient Name

First NameLast Name
Gender*
DOB*

MonthDayYear
Date
Today

MonthDayYear
Date
Age in Days
Age
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Grade Level*
Ethnicity*
Religious Preferences*
Height*
Weight*
Eye Color*
Hair Color*
Shoe Size*
Waist Size*
Shirt Size*
Identifying Marks

Parent or Guardian
Are you the Parent or Guardian?*

YesNo
- Contact for non Parent/Guardian
- Name of person filling out this form*
  
  First NameLast Name
- Relationship to Patient*
- Contact Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Contact Email*
  example@example.com
- Contact for Primary Parent/Guardian
- Name*
  
  First NameLast Name
- Relationship*
- DOB*
  
  MonthDayYear
  Date
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Mobile Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Home Phone (optional)
  Please enter a valid phone number.Format: (000) 000-0000.
- Email*
  example@example.com
- Physical Custody*
- Emergency Contact*
- SSN
- Employer*
- Job Title*
- Please describe the relationship between child and the above parent/guardian*
- Add Secondary Parent/Guardian*
  
  YesNo
- Contact for Secondary Parent/Guardian
- Name*
  
  First NameLast Name
- Relationship*
- DOB*
  
  MonthDayYear
  Date
- Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Mobile Phone*
  Please enter a valid phone number.Format: (000) 000-0000.
- Home Phone
  Please enter a valid phone number.Format: (000) 000-0000.
- Email*
  example@example.com
- Physical Custody*
- Emergency Contact*
- SSN
- Employer*
- Job Title*
- Please describe the relationship between child and the above parent/guardian

Email of person filling out this form*
This is the email used to receive a confirmation on form submission.
Phone of person filling out this form*
Please enter a valid phone number.Format: (000) 000-0000.
Address of person filling out this form*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone of person filling out this form
This is the email used to receive a confirmation on form submission.
Address of person filling out this form
This is the email used to receive a confirmation on form submission.
Emergency Contact
Name*

First NameLast Name
Relationship*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone (optional)
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com

Insurance Information
Is patient covered by private health insurance (please note we do not accept Medicaid)?*

YesNo
Private Pay*

Private Pay
- Name of Insurance*
- Member ID*
- Group #*
- Insurance Telephone Number*
  Please enter a valid phone number.Format: (000) 000-0000.
- Subscriber Name*
- Subscriber DOB*
  
  MonthDayYear
  Date
- Subscriber Relationship to Patient*
- Please attach a separate picture of both the front and back of your medical insurance card
  
  Cancelof

Referral Information
How did you learn about Turning Winds?*
What site?
Name of Parent

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name of Therapist
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of program or organization
Primary point of contact name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please describe

Are you currently working with an Education Consultant?*

YesNo
Name of Education Consultant*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Why is your child being referred to Turning Winds (please be specific)?*

Family Information & History
Was child adopted?*

YesNo
- At what age was child adopted?*
- Please briefly describe any pertinent information related to your child’s adoption and since*
- Does the child have contact and/or a relationship with biological parents?*
  
  YesNo
- Citizenship*
  
  YesNo
- Biological parents' current marital status*
- Who has legal custody of the child?*
- What was the date of divorce or separation?*
  
  MonthDayYear
  Date
- In what state was the divorce filed?*
- Is there a no-contact order?*
  
  YesNo
- Please briefly describe any pertinent information related to the divorce and impact on your child*
- Please attach a copy of the current custody agreement
  
  Cancelof

Where was your child born?
Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of hospital*

Please describe any complications related to pregnancy and birth
How many siblings does your child have?*
Please describe your child’s relationship with each sibling*

Is there a history of mental health issues in the family?*

YesNo
Please be specific*
Do any of these family members take prescribed and/or OTC medication; if so, has the medication been helpful/effective for them?
Please provide each family member relationship, mental health diagnosis, and current condition as it relates to the mental health diagnosis*

Is there a history of substance abuse in the family?*

YesNo
Please be specific*
Do any of these family members take prescribed and/or OTC medication; if so, has the medication been helpful/effective for them?
Please provide each family member relationship, substance use history (current and/or past), and current condition as it relates to the substance use:*

Treatment/Placement History

(Please include residential, psychiatric, and hospital placements; please include both inpatient and outpatient services)
Has your child received any type of professional treatment services including but not limited to residential treatment, outpatient treatment, therapy services, etc.?*

NoYes
- Treatment/Placement 1
- * Please start with most recent treatment history.
- Name of Program*
- Location*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Level of Care*
- Start Date*
  
  MonthDayYear
  Approximate start date
- End Date
  
  MonthDayYear
  Approximate end date
- Did patient complete treatment?*
- Therapist or Provider*
- Please describe the reason for placement*
- Outcome of placement; would you describe the treatment as successful?*
- Please describe aftercare following treatment (Did your child return home? Did your child follow-up with any aftercare services?):*
- Please provide primary point of contact (therapist, case manager, etc.) name, phone number, and email*
- Add a 2nd Treatment/Placement?*
  
  YesNo
- Treatment/Placement 2
- Name of Program*
- Location*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Level of Care*
- Start Date*
  
  MonthDayYear
  Approximate start date
- End Date
  
  MonthDayYear
  Approximate end date
- Did patient complete treatment?*
- Therapist or Provider*
- Please describe the reason for placement*
- Outcome of placement; would you describe the treatment as successful?*
- Please describe aftercare following treatment (Did your child return home? Did your child follow-up with any aftercare services?)*
- Please provide primary point of contact (therapist, case manager, etc.) name, phone number, and email*
- Add a 3rd Treatment/Placement?*
  
  YesNo
- Treatment/Placement 3
- Name of Program*
- Location*
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Level of Care*
- Start Date*
  
  MonthDayYear
  Approximate start date
- End Date
  
  MonthDayYear
  Approximate end date
- Did patient complete treatment?*
- Therapist or Provider*
- Please describe the reason for placement*
- Outcome of placement; would you describe the treatment as successful?*
- Please describe aftercare following treatment (Did your child return home? Did your child follow-up with any aftercare services?)*
- Please provide primary point of contact (therapist, case manager, etc.) name, phone number, and email*

Document any other Treatment/Programs here
Has your child ever physically attacked a patient or staff while in treatment (please be specific and provide dates)
Has your child had any psychological testing?*

YesNo
Please attach any medical records, testing, and/or evaluations

Cancelof
Please attach any psychological evaluations/biopsychosocial

Cancelof

Medical Profile
Primary Doctor (PCP)
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of last physical

MonthDayYear
Date
Does your child use contacts or wear glasses?*

YesNo
Date of last eye exam (applicable even if your child does not use/wear contacts or glasses):

MonthDayYear
Date
Has your child had a Tetanus Toxoid Inoculation within the last 10 years?*

YesNo
Has your child had any sexually transmitted diseases (e.g., Gonorrhea, Syphilis, Herpes)?*

YesNo
Please attach most up to date immunization records

Cancelof

Dentist
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Date of last dental exam:

MonthDayYear
Date
Does your child have braces?*

YesNo
Please note any dental related issues that we should be aware of during child’s placement at TW:
Please attach a separate picture of both the front and back of your dental insurance card

Cancelof

Please list and describe any other medical conditions we need to be made aware of
Has your child had any problems related to speech or hearing (please describe)?
Has your child had any surgeries or serious illnesses; was hospitalization required in any of these cases (please describe and provide dates)?

Has your child ever been hospitalized for psychiatric or psychological reasons (please describe and provide dates)?
Is your child in any way limited in their ability to participate in physical activities here at Turning Winds (e.g., skiing/snowboarding, hiking, camping, backpacking, kayaking, biking)?

Allergies & Asthma
Is your child allergic to any of the following?

MedicationSeasonalBees/Wasps & Insect Bites/StingsFoodNone
For each allergy, please provide the following: *

Does your child carry an epinephrine pen?*

YesNo
Does your child have asthma?*

YesNo
Does your child carry an inhaler?*

YesNo
Is your child’s physical activity limited due to Asthma (please describe)?
Has your child ever had to be hospitalized (or brought to the ER) due to allergies and/or asthma related issues (please describe and provide dates)?

Medication Continued
Has your child recently been taken off any medication (past 3 months)?*

YesNo
Please list name, dosage, length of prescription and briefly describe why your child stopped taking this medication*
Has your child been prescribed other medication in the past which they are no longer taking (over 3 months ago)?*

YesNo
Please list the name, dosage, length of prescription of the medication and briefly describe why your child stopped taking this medication*
Has your child ever had an adverse or negative reaction to a medication (e.g., weight gain, suicidal ideation)? Please describe:
Please briefly describe your child’s overall attitude towards medication:*
Please briefly describe your attitude and views towards prescription medication, over the counter medication, and supplements:*

Personality
Does your child have any hobbies (please describe)?
How would you describe your child (leader, follower)?*
Does your child make friends easily (please describe)?*
How would teachers describe your child?*
How would other parents, neighbors, extended family describe your child?*

Hygiene
Please describe your child’s general attitude towards hygiene and their hygiene practices (please be specific)*
Has your child currently or in the past struggled with bed wetting (please describe)?
Please describe your child’s teeth brushing habits (please be specific):*
Please describe your child’s showering/bathing habits (please be specific):*
Has your child currently or in the past refused to follow good hygiene habits (please describe)?

Behavior
Please describe your child’s behavior at home, specifically concerning behavior that has you seeking treatment for your child (How does your child interact with parents/guardians? How does your child interact with siblings? Please be specific and give examples):*
Has your child been verbally and/or physically aggressive or violent at home (pushing, shoving, property damage, etc.; please describe and provide dates)?*
Please describe your child’s behavior outside of the home (How does your child interact with peers? How does your child interact with teachers and other adults? How does your child do socially at school? Please be specific and give examples):*
Has your child been verbally and/or physically aggressive or violent outside of the home (pushing, shoving, property damage, etc.; please describe and provide dates)?*
Has your child ever shown any unusual behaviors such as delusions or hallucinations (please describe)?*
Does your child exhibit signs of anxiety, depression, or mood swings (please describe)?*
Does your child have any obsessions or compulsions (please describe)?*
Has your child every run away from home (please describe including how often, dates, for how long, end result)?*
Does your child have a history of lying, stealing, vandalizing, or other criminal activity (please describe)?*
Does your child have any past or present legal problems (please list dates, arrests, charges, convictions)?*
Does your child have a history of abusing animals (please describe)?*
Has your child ever engaged in any risky, aggressive, or inappropriate sexual behaviors such as promiscuity, unprotected sex, pornography, perpetrating deviance, etc. (please describe)?*
Does your child isolate from others (please describe)?*

Self-Harm & Suicide Screening
Has your child intentionally hurt themselves (please describe)?*
Does your child have a history of self-harm/cutting (please describe including frequency and dates)?*
Has your child ever been hospitalized and/or needed stitches for self-harm/cutting (please describe and include dates)?*
Has your child ever exhibited head banging behavior (please describe)?*
Has your child ever expressed thoughts of suicide, made a plan, and/or attempted suicide (please be specific and include dates; please list any hospitalizations if applicable)?*
Addiction/Addictive Behavior
Does your child have a history (active or past) of cigarette/nicotine, alcohol, or substance use/dependency issues (please list each substance, suspected age of first use, and suspected frequency of use)?*
Does your child exhibit any other addictive patterns/behaviors (phone, internet, sex, pornography, video games/computer games; please list and describe)?*

Education
Name of Current School:*
What is your child’s current grade level?*
Is your child currently attending school (if not, please list highest level of education completed)?*
Has your child dropped out of school?*

YesNo
Has your child ever been suspended or expelled from school (please describe and provide dates)?
Please describe your child’s overall current performance at school (attendance/participation, effort/motivation, grades; please be specific):*
Has there been any recent changes in your child’s academic performance (please describe)?
Typically, when your child is engaged and performing well, what kind of grades are they receiving?*
Is your child behind in credits (please describe)?
Please describe your child’s academic interest/strengths*
Please describe your child’s academic weaknesses/areas for improvement*
Has your child ever been evaluated for or diagnosed with a learning disability including ADHD, dysgraphia, dyslexia, or autism spectrum disorder (please describe)?
Does your child have an IEP or 504 Plan?*

YesNo
Please attach any evaluations if applicable

Cancelof
Please attach IEP or 504 Plan if applicable

Cancelof

Treatment Goals
What objectives do you hope to achieve by enrolling your child into Turning Winds?
Please describe the academic expectation/goals you have for your child while attending Turning Winds*
What are your plans after Turning Winds?*
Should be Empty:

Application Form

Patient/Student Information

Parent or Guardian

Contact for non Parent/Guardian

Contact for Primary Parent/Guardian

Contact for Secondary Parent/Guardian

Emergency Contact

Insurance Information

Referral Information

Family Information & History

Where was your child born?

Treatment/Placement History

Treatment/Placement 1

Treatment/Placement 2

Treatment/Placement 3

Medical Profile

Primary Doctor (PCP)

Dentist

Medical Profile

Allergies & Asthma

Medication

Medication 1

Medication 2

Medication 3

Medication 4

Medication 5

Medication Continued

Parent Assessment

Personality

Hygiene

Behavior

Self-Harm & Suicide Screening

Addiction/Addictive Behavior

Education

Treatment Goals