Online Application

P.O. Box 238, Loranger, LA 70446

Phone: (985) 878-6560 • Fax: (985) 878-9370
Admission Application

Contact Information for Resident / Parent / Guardian
Today's Date

MonthDayYear
Date
Enrollment Date

MonthDayYear
Date
Discharge Date

MonthDayYear
Date
In order to properly communicate, we need to have all contact information for the parent/guardian of the resident. We ask each parent/guardian to provide an email address so that we can keep you informed as well as provide you with updated documents, reportsandaccounting information.
Resident
Name
Nickname (if applicable)
Date of Birth

MonthDayYear
Date
Present Age
Social Security Number
Current Grade Level
For Year's
Parent or Guardian
Name
Relation to Resident
Date of Birth

MonthDayYear
Date
Mailing Address
City
State
Zip
Home Phone
Enter 10 digit phone numberFormat: (000) 000-0000.
Cell Phone
Enter 10 digit phone numberFormat: (000) 000-0000.
Work Phone
Enter 10 digit phone numberFormat: (000) 000-0000.
Fax
Enter 10 digit phone numberFormat: (000) 000-0000.
Email
example@example.com
Emergency Contact
Relation to Resident
Emergency Contact Phone(s)
Enter 10 digit phone numberFormat: (000) 000-0000.
As applicable:
Medicaid) INS (Name)
Name of Plan
TipsGroup # (State Placement)
Attorney Name
Number
Probation Officer
Number
CASA
Number
Admission Application

Current Family Data
- Full Name
- Current Address
- Current Number
  Enter 10 digite phone numberFormat: (000) 000-0000.
- Birth Place / Birth Date
- Social Security #
- Name of Church
- Pastor's Name
- Pastor's Number
  Enter 10 digite phone numberFormat: (000) 000-0000.
- Occupation
- Employer
- Work Hours
- Work Phone Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Other Phone Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Salary (Annual)
- Highest Grade Level Completed
- Marital Status
- Name of Spouse
- Date of Marriage
  
  MonthDayYear
  Date
- Date of Divorce
  
  MonthDayYear
  Date
- If Deceased, Date of Death
- Cause of Death
- Full Name
- Current Address
- Current Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Birth Place / Birth Date
- Social Security #
- Name of Church
- Pastor's Name
- Pastor's Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Occupation
- Employer
- Work Hours
- Work Phone Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Other Phone Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Salary (Annual)
- Highest Grade Level Completed
- Marital Status
- Name of Spouse
- Date of Marriage
  
  MonthDayYear
  Date
- Date of Divorce
  
  MonthDayYear
  Date
- If Deceased, Date of Death
- Cause of Death
- Full Name
- Current Address
- Current Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Birth Place / Birth Date
- Social Security #
- Name of Church
- Pastor's Name
- Pastor's Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Occupation
- Employer
- Work Hours
- Work Phone Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Other Phone Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Salary (Annual)
- Highest Grade Level Completed
- Marital Status
- Name of Spouse
- Date of Marriage
  
  MonthDayYear
  Date
- Date of Divorce
  
  MonthDayYear
  Date
- If Deceased, Date of Death
- Cause of Death
- Full Name
- Current Address
- Current Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Birth Place / Birth Date
- Social Security #
- Name of Church
- Pastor's Name
- Pastor's Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Occupation
- Employer
- Work Hours
- Work Phone Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Other Phone Number
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Salary (Annual)
- Highest Grade Level Completed
- Marital Status
- Name of Spouse
- Date of Marriage
  
  MonthDayYear
  Date
- Date of Divorce
  
  MonthDayYear
  Date
- If Deceased, Date of Death
- Cause of Death
- Who is authorized to give consent for child?
- Relationship
- Emergency Contacts (Provide at least 3 contacts)
- Name
- Relationship
- Phone
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Name
- Relationship
- Phone
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Name
- Relationship
- Phone
  Enter 10 digit phone numberFormat: (000) 000-0000.
- Admission Application
  
  Family History
- 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.
- Please Initial Here
- 2. Provide assistance to Ranch personnel when needed to assist your child
- Please Initial Here
- 3. Maintain contact with your child via telephone, mail and actual visits according to the Ranch program schedules.
- Please Initial Here
- 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.
- Please Initial Here
- 5. Agree to promptly pay your monthly obligations to the Ranch.
- Please Initial Here
- 6. Willing to assist with any future paperwork as may be deemed necessary by the Ranch and respond expeditiously to requests when notified.
- Please Initial Here
- 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
- Date
  
  MonthDayYear
  Date
- Signature of person completing this application
- Date
  
  MonthDayYear
  Date
- Admission Application
  
  Medications Form
- Current Prescribed Medications
- Patient
- Date
  
  MonthDayYear
  Date
- Medication
- MG
- Amt. of Refills
- Refill DT.
- Time of Dosage
- Medication
- MG
- Amt. of Refills
- Refill DT.
- Time of Dosage
- Medication
- MG
- Amt. of Refills
- Refill DT.
- Time of Dosage
- Medication
- MG
- Amt. of Refills
- Refill DT.
- Time of Dosage
- Medication
- MG
- Amt. of Refills
- Refill DT.
- Time of Dosage
- Special Instructions
- Parent/Guardian Signature
- Date
  
  MonthDayYear
  Date
- Non-Prescription (Over the Counter) Medication List
- Non Prescription Med.
- Non Prescription Med.
- Non Prescription Med.
- Special Instructions
- Parent/Guardian Signature
- Date
  
  MonthDayYear
  Date
- Admission Application
  
  History and Psychosocial Information
- 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)
- Education:
- Current Grade
- Name of School
- Last three schools attended
- Does resident have an IEP?( If so, describe)
- Describe resident's history of school attendance
- Social History:
- 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
- Should be Empty:

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: