Lakeside Academy Application

  • Lakeside Academy Application

  • Applicant's Information:

  • Gender:*
  • Date of Birth:*
     - -
  • My Child Mainly Needs Help With: (Check All That Apply)*

  • Applicant's Demographics:

  • Race:*
  • Custody Status:*
  • Adopted:*

  • Primary Parental/Guardian's Information:

  • Date of Birth:*
     - -
  •  -
  •  -

  • Secondary Parental/Guardian's Information:

  • Date of Birth:
     - -
  •  -
  •  -

  • Applicant's Insurance Information:

  • Does your child have medical insurance?*

  • If yes, please provide the following information:

  • Policy Holder's Date of Birth:*
     - -
  • Format: (000) 000-0000.
  • Do you have secondary insurance?*

  • Important Note:

    This is for supplemental medical needs while in the program. (i.e. doctor’s visits, prescriptions, etc.) Not all insurance plans cover out-of-state clinics and services. If deemed necessary, a student may need to be seen by a local clinic while in the program. If insurance does not cover the medical visit, parents will be billed directly by the clinic for services
  • How did you hear about Lakeside Academy?*
  • Today's Date:*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • In your own words, tell us why you want your child to come to Lakeside Academy and the main issues you believe your child needs to deal with while in the program pertaining to the following areas:

  • Strengths and Assets Inventory

  • Please Check All That Apply:*

  • Reviewed Medications

    The following medications are reviewed at Minnesota Adult & Teen Challenge due to their interference with the recovery process. Examples of reviewed medications include, but are not limited to, the following:

  • Medical Marijuana

  • Medications used Specifically for Weight Loss

  • Muscle Relaxants

  • Stimulant Medications

  • Performance Enhancing Steroids/Supplements, or Herbal Supplements

  • Essential Oils

  • Scheduled/Controlled pain relievers, unless pre-approved

  • Antabuse

  • Medication Assisted Treatment (MAT)

    The use of medications in combination with counseling, and behavioral therapies.

  • Sleep Aids

    Melatonin can be taken as a specific sleep aid and clients with a psychiatric diagnosis may use mental health medications that also treat sleep disturbances.

  • Important Note:

    Minnesota Adult & Teen Challenge has an approved list of OTC medications that clients may purchase on their own.

  • Physical Health

  • Medical History: (Check all that apply to child's current and past conditions)*
  • Does your child have any current medical concerns?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Start Date of Treatment:
     - -
  • End/Current Date of Treatment:
     - -
  • Date of Last Full Physical Examination:
     - -
  • Is your child allergic to any medications?*
  • Is your child being treated with prescribed narcotics/benzodiazepine/opiate/prohibited medications?*
  • Are you willing to adjust your child’s medication to an approved med with prescribing doctor permission?*

  • Important Note:

    Applicants on these types of medications or ingesting any of the above will need to complete the taper regimen prior to admission or switch to approved medications under doctor supervision.

  • Special Needs:

  • Does your child have any type of disability?*
  • Does your child have any chronic conditions*
  • Does your child have any medical restrictions?*
  • Does your child have any other type of special needs?*
  • Does your child have any allergies?*
  • Does your child have a special diet?*

  • Mental Health

  • Mental Health History: (Only check the following conditions if diagnosed by a professional.)*
  • Has your child thought about, or attempted suicide in the past 3 months?*
  • Are you aware of your child having access to or viewing “The Dark Web?”*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Start Date of Treatment:
     - -
  • End Date of Treatment:
     - -
  • Rows
  • Has the student had a diagnostic assessment (DA) in the last 6 months?*
  • Has the student had a NeuroPsychological Evaluation/Test been completed?*
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  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Legal Issues

  • Is your child currently on probation?*
  • Does your child currently have any court cases pending?*
  • Is your child currently under investigation for anything?*
  • Does your child currently have any outstanding warrants?*
  • Has your child ever been deemed incompetent? (Rule 20)*
  • Has your child ever been convicted of a violent crime?*
  • Has your child ever been convicted of a sex related crime?*
  • Is your child currently facing charges for a violent or sex related crime?*
  • Is your child required to register as a sexual or predatory offender?*
  • Is your child required to “Notify the Community” or police department?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Emergency Contacts

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Substance Use

  • Check all known substances used:*
  • Is your child abusing substances?*
  • If yes, what is the last date of use?*
     - -

  • Previous Treatment for Substance Abuse:

  • Residential Alcohol and Drug Treatment

    (List the most recent programs your child has been in)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Start Date of Program:
     - -
  • End Date of Program:
     - -
  • Did your child complete the program?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Start Date of Program:
     - -
  • End Date of Program:
     - -
  • Did your child complete the program?

  • Out-Patient Alcohol and Drug Treatment

    (List the most recent program your child has been in)
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Start Date of Program:
     - -
  • End Date of Program:
     - -
  • Did your child complete the program?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Start Date of Program:
     - -
  • End Date of Program:
     - -
  • Did your child complete the program?

  • Please submit copies of the following with this application:

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  • School/Educational

    Please request a copy of your child's transcripts from their current school and IEP or 504 Plan ASAP and/or include it when you submit this application.
  • Date of Birth:
     - -
  • 1. Is your child currently enrolled in school?*
  • 2. Is your child home-schooled?*
  • 3. Does your child read and write English at a 5th grade level or above?*
  • a. Does your child require ESL classes?*
  • 4. What is your child's current grade level?*
  • a. Are your child's credits on course for graduation and include transcripts requirement so that course can be assigned by orientation date?*
  • 5. Are they on an IEP (Individualized Education Plan/Program)?*
  • 6. Do they have a 504 accommodation?*
  • 7. To your knowledge is your son on an RTI (Response to Intervention) plan?*
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  • Most Recent School Attended:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • IN ACCORDANCE WITH REVISED FEDERAL AND STATE STATUTES, PERMISSION OF THE PARENT OR ADULT IS NO LONGER REQUIRED WHEN RECORDS ARE REQUESTED BY AUTHORIZED SCHOOL PERSONNEL

  • Voluntary Compliance with Faith Based Activities

    Lakeside Academy is a faith-based program that is based upon Christian principles and practices. If you do not want your son to participate in this program and follow the requirements listed below, please contact our admissions department and we will provide a referral list of other programs that may better meet your needs. If you object to the spiritual education model utilized by Lakeside Academy and object to the religious character of this organization, Federal law gives you the right to a referral to another provider. The referral, and your receipt of alternative services, must occur within a reasonable period of time after you request them.

  • Please read each item carefully and initial your acceptance to each program requirement.

  • Upon admittance to Lakeside Academy, I understand the following (please initial each line):

  • My signature below indicates that I have carefully considered the Christian nature of the program and have made a free and independent choice to participate in the Lakeside Academy program. I also acknowledge that I have been given the opportunity to ask for a referral list of other faith-based and secular programs.

  • I have spoken with my child about placing him/her in a faith-based program*
  • Date*
     - -
  • Date
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  • Full Disclosure to Minor

    Lakeside Academy (LA) holds the position that full disclosure is the best method for placing a minor in our program. While most teenagers will not be happy about having to relocate to a new living situation, LA still requires a minimum awareness of the decision to be placed at LA. The minor should be informed in advance of the timeframe for placement, including the specific time and day for intake.

  • Additionally, the following items must be presented to the minor prior to intake:

     Lakeside Academy is Faith-based/Christian program  Program duration is a four level program up to twelve months  I acknowledge that if my child is discharged from the program, it is my responsibility to make sure that he leaves the facility within the time parameters set forth by Lakeside Academy Leadership.  I acknowledge that if my child runs from the campus the Wright County Sheriff’s Department is called and they will apprehend my son.  If my child has been involved in problematic behavior at the program setting or outside the program setting and/or breaks the law, he may be charged with a crime and face court consequences including incarceration, fines, probation, etc.

  • 3rd Party Transportation Services

     Admission by a transport service is allowed on a case-by case basis  Although transport services can be expensive, this may be an option to bring your son to LA; however, the same full disclosure policy still applies  If a minor arrives via transport without a reasonable amount of compliance upon arrival, the parent/guardian will be responsible for making immediate arrangements for the minor to return home

  • I understand these expectations and herby acknowledge acceptance of these terms. I also acknowledge that if a minor arrives at LA without prior knowledge, LA retains the right to rescind acceptance into the program.

  • Date*
     - -
  • Date
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  • Parental Release of Liability Agreement

  • I/We,      , parent(s), guardian(s), or conservator(s) of
          , a minor child, born on   Pick a Date   , hereby agree that he/she can enroll in Lakeside Academy (LA) and Minnesota Adult and Teen Challenge (MnTC), a therapeutic boarding school. I/We further agree that I/we relieve LA/MnTC, its staff, employees, students, and board members from
    any responsibility or liability for any damages to him or his property during his residence at LA/MnTC or during any related travel and/or activities. I/We also agree to release, hold harmless, and relinquish all rights to pursue any cause of action whatsoever against LA/MnTC, its staff, employees, students, and board members if a
    resident voluntarily leaves LA/MnTC or for any damages incurred during his residence. I further acknowledge that LA/MnTC is not a lock down facility and that in the event my child runs away from the facility, LA staff will contact Wright County Sherriff Department to report the minor child as a runaway. Lakeside Academy will make every reasonable effort to return a former clients property we reserve the right to dispose of the property after 30 days. 

  • Date*
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  • Date
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  • Emergency Medical, Surgical, and Dental Permit

    Lakeside Academy may provide emergency services anytime the parent(s), guardian(s), or emergency contact person(s) cannot be reached, when, in the opinion of the attending, duly qualified physician, said services are deemed necessary or advisable. I/we consent to the administration of whatever anesthetics are advisable or necessary and I/we agree to be solely responsible for payment of any and all medical or dental services obtained.
  • Date*
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  • Date
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  • APPLICANT’S STATEMENT

    By my signature below, I certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that should an investigation disclose untruthful or misleading answers, my child may be discharged from the Lakeside Academy program. Furthermore, I understand that Lakeside Academy is a Christian, faith-based program and that I have made a free and independent choice to enroll my child. I understand that other program options are available to me and I have had an opportunity to request a referral. I agree that that I will settle any and all previously asserted claims, disputes or controversies arising out of or relating to my application, participation in and discharge from the Lakeside Academy program with Lakeside Academy by final and binding arbitration in accordance with the applicable American Arbitration Association rules of arbitration in effect on the date that arbitration is requested by either me or Lakeside Academy. I agree that all administrative costs of arbitration shall be divided equally among the parties.

  • Please initial indicating that you have received, read, and agree to abide by the following documents:

  • Date*
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  • Date
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  • Program Costs: Enrollment, Tuition, Deposits, and Other Fees

  • Cost of Program

    Standard tuition covers: room & board (breakfast, lunch, dinner, and snack daily), 24/7 direct care staff, academic support for online school (classroom teacher), daily vocational experience (i.e. woodshop, welding, automotive, etc.) on-site recreational activities, individual and group counseling sessions and other basic behavioral groups.

  • Damage Deposit: $500.00 (Please bring cash, check, or credit card on day of admission)

    A damage deposit is required for all applicants at the time of admission. Money from thisdeposit will be used to repair or replace damaged property caused by the student.Parents/guardians are required to replace money used from the damage deposit so that a$500.00 deposit is maintained at all times. A minimum charge of $50 will be charged perincident. Upon discharge, the damage deposit minus any damage expenses will be refunded.

  • Personal Needs Money: $300.00 (Please bring cash, check or credit card on day of admission)

    The client personal account in which the client’s parent places money in to, is not for them touse at their leisure. The account is used for incidentals, haircuts, sometimes rec events as well asreward center.

  • Program Costs: Tuition, Deposits, and Other Fees (cont.)

  • Program Fee Philosophy

    It is common for boarding school and treatment programs to exceed $150,000, LAKESIDE ACADEMY will strive to keep your total yearly (12 months) out of pocket expenses down so that they do not exceed the amount of your deposit. Even if the services provided to your child greatly exceed your deposit, LAKESIDE ACADEMY will work with your insurance company and will utilize scholarships, grants, other third-party payers, debt forgiveness, etc. to accomplish its commitment to cap your total out of pocket expenses.LAKESIDE ACADEMY offers a discount if you choose to pay the entire deposit at the time of your son’s admission. We do understand that this may not be a feasible option for your family so LAKESIDE ACADEMY offers a 12 month payment plan. The first payment will include the first month and a non-refundable deposit. This amount is due at the time of admission. The details of the program fees and payment plan will be discussed in more detail with LAKESIDE ACADEMY’S admission staff.

  • Cost of Program

    LAKESIDE ACADEMY will have two (2) cost plans: (1) with insurance and (2) without insurance. Within each of these plans, families will be able to receive a discount for full payment at time of admissions or commit to making payments over 12 months.

  • Cost of program with insurance:

    Payment is made in full receiving 5% discount Payment is made over 12 months $48,605

  • Cost of program without insurance:

    Payment is made in full receiving 5% discount Payment is made over 12 months $63,600

  • Refund Policy

    Any excess funds or deposit monies remaining in the client/student’s account will be refunded within 30 days of the child’s discharge from the program. The refunds are calculated based on the balance of unpaid services.

  • I have read the statements above regarding the financial obligations of enrolling my son at Lakeside Academy and agree to these terms.

  • Date*
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  • Date
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  • If you experience problems with the submit button below, please call (844) 768-8336 or reach out to us through our Contact Us page.

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