The Reagan Admission Assessment

Admission Assessment
Notice to Parent/Guardian: The purpose of this assessment is to provide an initial evaluation of the appropriate placement of your child, and to ensure that we, The Reagan, obtain the necessary information to facilitate placement and treatment services for your child. Please respond accurately and completely with all information requested in this form.
Demographic Information
Full Legal Name*

First NameMiddle InitialLast Name
Gender*
Date of Birth*

MonthDayYear
Level of Care*
SSN*
DFPS PID
Medicaid Number
Language Spoken
Religion
Race
Ethnicity
Height
Weight
Hair Color
Eye Color
Legal Information
Legal Status
Legal Region
Legal County
Date of Conservatorship

MonthDayYear
Date
Dismissal Date

MonthDayYear
Date
Parental Rights Terminated?
Next Court Date

MonthDayYear
Primary Permanency Goal
Concurrent Permanency Goal
Contact Info of Person Filling Out this Application
Name

First NameLast Name
Title
Phone
Please enter a valid phone number.
Email
example@example.com
DFPS Contact Information
DFPS Caseworker
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
DFPS Supervisor
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Attorney Ad Litem
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Guardian Ad Litem
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Family Relationships
List all immediate family members and any relatives with whom the youth has had a significant relationship.
Describe the youth's family history, home environment, and family functioning.
Trauma History
Describe the circumstances that led to the youth's referral for substitute care
Describe youth's abuse/neglect history.
Aces

Check the box for all responses that are applicable to the youth's history.
1. Did a parent or other adult in the household often or very often… a) Swear at you, insult you, put you down, or humiliate you? or b) Act in a way that made you afraid that you might be physically hurt?

YesNo
2. Did a parent or other adult in the household often or very often… a) Push, grab, slap, or throw something at you? or b) Ever hit you so hard that you had marks or were injured?

YesNo
3. Did an adult or person at least 5 years older than you ever… a) Touch or fondle you or have you touch their body in a sexual way? or b) Attempt or actually have oral, anal, or vaginal intercourse with you?

YesNo
4. Did you often or very often feel that … a) No one in your family loved you or thought you were important or special? or b) Your family didn’t look out for each other, feel close to each other, or support each other?

YesNo
5. Did you often or very often feel that … a) You didn’t have enough to eat, had to wear dirty clothes, and had no one to protect you? or b) Your parents were too drunk or high to take care of you or take you to the doctor if you needed it?

YesNo
6. Were your parents ever separated or divorced?

YesNo
7. Was your parent/caregiver: a) Often or very often pushed, grabbed, slapped or had something thrown at her? or b) Sometimes, often, or very often kicked, bitten, hit with a fist, or hit with something hard? or c) Ever repeatedly hit over at least a few minutes or threatened with a gun or knife?

YesNo
8. Did you live with anyone who was a problem drinker or alcoholic, or who used street drugs?

YesNo
9. Was a household member depressed or mentally ill, or did a household member attempt suicide?

YesNo
10. Did a household member go to prison?

YesNo
Placement History

Please complete the table with all information available regarding the youth's history of out-of-home placement.

	Placement Date	Placement Type	DFPS Placement?	Discharge Date	Discharge Reason
1
2
3
4
5
6
7

Behavioral Health
Describe child's behavior within last 30 days, including appropriate and maladaptive behaviors and any high risk behaviors.
Describe the youth's behaviors that are most challenging.
Are there contraindications to the use of restraints for this youth?
If yes, please describe.
Describe recommendations for evaluation, treatment & behavioral management
Describe the youth's personality, skills/abilities and special interests.
Describe any intellectual delays, diagnoses, or disabilities the youth has.
Describe youth's developmental history
Describe youth's current developmental functioning
Medical
Medical Consenter
Is the youth her own medical consenter?
Last Medical Exam

MonthDayYear
Next Due

MonthDayYear
Last Dental Exam

MonthDayYear
Next Due

MonthDayYear
Last Vision Exam

MonthDayYear
Next Due

MonthDayYear
Last Hearing Exam

MonthDayYear
Next Due

MonthDayYear
Summary of youth's dental needs
Summary of youth's vision needs
Summary of youth's hearing needs
Please attach any available results or records of the youth's past medical, dental, vision, or hearing.

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Describe youth's medical health
Describe any chronic health conditions the youth has
Describe youth's health history in the past 3 months including any Surgery, Illnesses, ER/Urgent Care Visits, On going pain
Describe any allergies to foods, animals, environment, medication, etc.
Describe youth's dietary restrictions, if any
Please attach a copy of the youth's most up to date immunization record.

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Medication

Non-Psychotropic Medications

	Current Non-Psychotropic Medications prescribed to the youth	Prescribing Physician (Include contact information)	Dosage and Frequency	Purpose	Side Effects	Last Review Date
1
2
3

Psychotropic Medications

	Current Psychotropic Medications prescribed to the youth	Prescribing Physician (Include contact information)	Dosage and Frequency	Disorder and Symptoms Treating	Side Effects	Last Review Date
1
2
3
4

Mental Health
Describe youth's Mental Health history and current status.
Please provide the following information for assessments and evaluations the youth has completed.

The Reagan cannot consider for this admission assessment, any mental health assessment or evaluation completed more than 6 months in the past unless the youth is transitioning from a paid/regulated placement. All evaluations and assessments reported here must have been completed within the last 13 months for youth coming from other paid placements.

	Evaluation Type	Evaluation Date	Practitioner	Diagnoses	Recommendations
1
2
3
4
5
6

Describe youth's therapy history, including therapy type, frequency, duration, ages the youth attended therapy and the youth's reaction to therapy.
Describe youth's coping skills
Substance Abuse
Describe youth's substance abuse history (including substances used, frequency, duration, level of dependency, last use, and any other pertinent information)
Is the youth currently experiencing any substance abuse or dependency?
Please attach copies of all available reports from past substance abuse or mental health evaluations the youth has completed.

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Juvenile Justice Involvement
Describe all past or current Juvenile Justice involvement.
Education

Type a question

	School Name	Grade Level	Dates Attended	Summary of Academic Performance (Include grades earned and special achievements)
1
2
3
4

Describe youth's current education level/functioning.
Describe any school issues the youth has had during the most recent school year.
Does the youth receive any Special Education Services or 504 Modifications?
Treatment Services
The Reagan is a residential program of Unbound Now Waco. The Reagan is Licensed as a General Residential Operation Providing Multiple Services, including treatment services for youth who have experienced sexual exploitation or human trafficking. The Reagan seeks to provide a safe, trauma informed, home environment to build trust and lasting coping skills for a full recovery from the trauma of sexual exploitation.

The Reagan’s program is modeled around the principles of trauma informed care. All staff of The Reagan are trained in Trust Based Relational Intervention (TBRI) and interactions with the youth will be based on the TBRI principles of Connecting, Empowering and Correcting. The youth of The Reagan will participate in regular group therapy sessions alongside individualized trauma therapy to meet each of the youth’s specific mental health needs. The youth will have the opportunity to participate in therapeutic and recreational activities to build coping skills and promote healthy recovery such as: horseback riding, hiking, trauma informed yoga, painting, and other therapeutic recreational activities.

Unbound Now Waco has built strong community partnerships with local organizations who will walk alongside the youth of The Reagan during placement and post-discharge, when applicable. Each youth will be assigned an Unbound Now Waco survivor advocate, who will provide emotional support and ongoing case management while the youth is placed at The Reagan.

Waco Family Medicine will provide all necessary medical care to youth placed at The Reagan, including medical checkups, medication needs, and counseling.
Youth placed at The Reagan will attend school at the Methodist Children’s Home Charter School, which provides a TBRI trained, trauma informed campus environment. The youth will have the opportunity to participate in school activities such as sporting events, school clubs, and other extracurriculars
Describe your recommendations for behavior management for the youth.
Describe your Short Term goals for the youth in placement at The Reagan.
Describe your Long Term goals for the youth in placement at The Reagan.
Describe the youth's understanding of placement at The Reagan.
Describe the youth's desires from placement at The Reagan.
Life Skills
Has the youth completed a CANS Assessment within the last 6 months?

YesNo
Has the youth completed a Casey Life Skills Assessment within the last 6 months?

YesNo
Has the youth completed PAL classes?

Not StartedStarted; Not CompleteCompleted
Has the youth had a Circle of Support or other Transitional Planning Meeting?

YesNo
Does the youth have their original documents (Check all that apply)?

ID/DLBirth CertificateSS CardMedicaid Card
Describe your expectations of The Reagan for youth's Life Skills Development
Should be Empty:

Admission Assessment

Demographic Information

Legal Information

Contact Info of Person Filling Out this Application

DFPS Contact Information

DFPS Caseworker

DFPS Supervisor

Attorney Ad Litem

Guardian Ad Litem

Family Relationships

Trauma History

Aces

Placement History

Behavioral Health

Medical

Medication

Mental Health

Substance Abuse

Juvenile Justice Involvement

Education

Treatment Services

Life Skills