Online Application

Who is authorized to give consent for child? *

Relationship *

Emergency Contacts (Provide at least 3 contacts)

Name *

Relationship *

Phone *

Enter 10 digit phone number

Name *

Relationship *

Phone *

Enter 10 digit phone number

Name *

Relationship *

Phone *

Enter 10 digit phone number

What problems have existed in this child's natural or foster family? Check all that apply *

Family Involvement

Please indicate your willingness to adhere to and/or participate as necessary:

1. Adhere to telephone, mail and visitation policies. *

Yes No

Please Initial Here *

Clear

2. Provide assistance to Ranch personnel when needed to assist your child *

Yes No

Please Initial Here *

Clear

3. Maintain contact with your child via telephone, mail and actual visits according to the Ranch program schedules. *

Yes No

Please Initial Here *

Clear

4. Willing to provide for incidental charges as necessitated by your child (i.e.: school charges, clothing, shoes, haircuts, dental & eyeglasses/Contacts and medical charges, etc. *

Yes No

Please Initial Here *

Clear

5. Agree to promptly pay your monthly obligations to the Ranch. *

Yes No

Please Initial Here *

Clear

6. Willing to assist with any future paperwork as may be deemed necessary by the Ranch and respond expeditiously to requests when notified. *

Yes No

Please Initial Here *

Clear

I hereby request that the Lighthouse Ranch for Boys consider providing services to the above-named child. All information provided is accurate to the best of my knowledge. I understand that any deliberately false information is grounds for denial into the program.

Signature Of Custody Holder *

Clear

Date *

Date

Signature of person completing this application *

Clear

Date *

Date

Current Prescribed Medications

Patient *

Date *

Date

Medication

MG

Amt. of Refills

Refill DT.

Time of Dosage

AM PM

Medication

MG

Amt. of Refills

Refill DT.

Time of Dosage

AM PM

Medication

MG

Amt. of Refills

Refill DT.

Time of Dosage

AM PM

Medication

MG

Amt. of Refills

Refill DT.

Time of Dosage

AM PM

Medication

MG

Amt. of Refills

Refill DT.

Time of Dosage

AM PM

Special Instructions

Parent/Guardian Signature *

Clear

Date *

Date

Non-Prescription (Over the Counter) Medication List

Non Prescription Med.

Special Instructions

Parent/Guardian Signature *

Clear

Date *

Date

Name of Potential Resident *

Guardian *

Tell us why you are seeking services from Lighthouse Ranch for Boys (include current behaviors/concerns) *

Custody Status/Current Placement *

History of Abuse (Physical, Sexual, Emotional) (Include age of abuse) *

Is resident a victim of sexual abuse? *

Is resident a perpetrator of sexual abuse? *

If yes to any above, describe treatment received

Does resident have a history of suicide/homicidal attempts or threats? *

Does resident have a history of alcohol use, prescription drug misuse or illegal drug use? (If so, describe including drug of choice) *

Past Hospitalizations (Y/N) If yes, describe when, where hospitalized: *

Current Diagnosis *

Current Medications (include name of prescribing physician) *

Medications attempted previously (include dates/year attempted and reason for d/c) *

Any known allergies? *

Name of current mental health provider and clinic: *

Name of Pediatrician or Primary Care Provider *

Does resident currently have pending criminal charges? (Y/N) *

Probation Officer(Y/N) *

Name / Number (if applicable): *

Jurisdiction and description of charges *

Does resident/caregiver report any of the following: trouble sleeping, trouble with appetite, cruelty to animals, starting fires, or refusal to take medication? (If so, describe length of time reported and failed interventions) *

Has resident received psychological testing? (If so describe, when, where and outcomes) *

Current Grade *

Name of School *

Last three schools attended *

Does resident have an IEP?( If so, describe) *

Describe resident's history of school attendance *

Does resident have hobbies or interest? If so, what are these? *

Any other information you wish to provide

P.O. Box 238, Loranger, LA 70446

Admission Application

Resident

Parent or Guardian

As applicable:

Admission Application

Emergency Contacts (Provide at least 3 contacts)

Admission Application

Family Involvement

Admission Application

Current Prescribed Medications

Non-Prescription (Over the Counter) Medication List

Admission Application

Education:

Social History: