Idaho Youth Ranch: RCH&R Application
Thank you for applying to the Idaho Youth Ranch: Residential Center for Healing and Resilience. If you have questions prior to completing this application. Please, fee free to reach out to one of our Intake Coordinator's by calling the RCH&R main phone line at (208) 996-2896 or by filling out the IYR "Get Help" form online. Otherwise, please proceed with this application by selecting "Next" below.
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Youth Applicant Information
1. Name of Youth Applicant
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First Name
Last Name
2. Preferred Name of Youth
3. Gender at Birth
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4. Identifies as Gender
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5. Date of Birth
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Month
-
Day
Year
Date
6. Age
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7. Height
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8. Weight
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9. Race
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American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other
10. Ethnicity
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Hispanic or Latino
Not Hispanic or Latino
11. In which city and state was this youth born?
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12. Street Address
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13. City / State / Zip
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14. Does your child have a religious/spiritual preference?
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Parent/Guardian Information
15. Name
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First Name
Last Name
16. Relationship to Youth (e.g., "biological mother," "stepfather," "foster parent," etc.)
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17. Street Address
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18. City / State / Zip
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19. Home Phone
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20. Mobile Phone
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21. Work Phone
22. Email
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23. Legal Custody
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Yes
No
24. Physical Custody
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Yes
No
25. Emergency Contact
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Yes
No
Parent/Guardian Information
26. Name
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First Name
Last Name
27. Relationship to Youth (e.g., "biological mother," "stepfather," "foster parent," etc.)
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28. Street Address
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29. City / State / Zip
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30. Home Phone
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31. Mobile Phone
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32. Work Phone
33. Email
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34. Physical Custody
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Yes
No
35. Emergency Contact
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Yes
No
36. Legal Custody
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Yes
No
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Family and Living Environment
37. Describe your child's current living situation. Please include how long they have lived there, who else lives in the home, and their relationship to your child.
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38. What is the primary language spoken in the home?
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39. Is your child adopted? Please explain.
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40. Is the child currently in Foster Care? Please explain.
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41. Who has custody of your child? If shared, please indicate the approximate ratio of time shared between caregiver.
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Referral Information
42. What is the reason for the referral? (Please be specific, including issues at home and school, major stressors, changes in mood, etc.)
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43. What are specific goals for your child while they are in treatment?
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44. What would you describe as your child's strengths (intellectually, artistically, socially, physically, etc.)?
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45. Describe your child's challenges (intellectually, socially, physically, etc.)?
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Psychological History
46. List any mental health diagnoses, they currently have or have been given, and how long they have had that diagnosis (if possible). Please describe.
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47. Please describe any major events your child has struggled with (divorce, moving, birth of sibling, loss, death, abuse, trauma, illness, etc.) Please include the approximate date the event occurred.
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48. Please list all prior psychiatric placements, including date/duration. Include psychiatric hospitalization, residential treatment, day treatment, partial hospitalization, and IOP.
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49. Describe how your child expresses anger.
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50. Has your child had any physical confrontations in the home or with others? Please describe.
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51. Has your child ever intentionally hurt him/herself, without the intent to die? Please describe. When did the most recent incident occur? Please describe frequency and duration.
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52. Has your child ever run away? Please describe, including the date, length of time, where, etc.
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53. Has your child ever had thoughts of suicide, made a plan, or attempted suicide? Please describe, including the approximate date, how the attempt was made, treatment needed, etc.
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54. Has your child ever engaged in any risky, aggressive, or inappropriate sexual behaviors (promiscuity, unprotected sex, perpetrating, deviance, predatory behaviors etc.)? Please describe.
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55. Does your child exhibit signs of anxiety, depression, mood swings, etc.? If so, please describe, frequency, duration, and most recent incident
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56. Does your child experience recurrent thoughts or repeated behaviors that he/she cannot control? If so, please describe frequency, duration, and most recent incident.
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57. Does your child have a history of stealing, lying, vandalism, dealing drugs or other criminal activity? Please describe.
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58.Fire-Setting Behavior-Has the youth ever intentionally set a fire or attempted to start a fire (including small fires, burning objects, or playing with ignition sources) outside of supervised or age-appropriate activities? If so, please describe including frequency, duration, and most recent episode.
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59. Fire Fascination or Risk-Has the youth demonstrated ongoing fascination with fire, repeated fire-setting behaviors, or difficulty following safety rules related to fire, heat sources, or ignition materials? If yes, please describe frequency, age of onset most recent incident, level of supervision required, and any injuries, property damage, or safety interventions.
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60. Has your child ever harmed any animals? Please describe.
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61. Has your child ever experienced Psychosis, if so, please describe frequency, duration, and most recent incident.
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62. Has your child ever experienced hallucinations, if so, please describe frequency, duration, and most recent incident.
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63. Has your child ever had any disordered eating patterns (binging, purging, restricting, etc.)? If so, please describe frequency, duration, and most recent incident.
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64. Is there a history of mental illness, or substance abuse in the family (depression, anxiety, etc.) If yes, describe including who, relationship to child, current status, etc.
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Substance Use Information
65. Does your child have a history of cigarette/nicotine, alcohol or substance use or dependency issues? If yes, please describe when you first noticed substance use, the substances used, usage patterns and frequencies, and how administered.
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66. Is there a family history or drug or alcohol abuse? If yes, describe including who, relationship to child, current status, etc.
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67. Does your child show any other addictive patterns (internet, TV, phone, pornography, gambling, etc.)? Please describe.
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Legal Information
68. Has your child ever got into legal trouble? If yes, please list any charges, convictions, misdemeanors, felonies, probation and current legal status. (If on probation please, include Probation officers name, and contact information).
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69. Has the youth ever been charged, adjudicated, or investigated for fire-setting or arson-related behaviors?
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Medical Information
70. Please list the approximate date of your child's last physical exam.
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Month
-
Day
Year
Date
71. Please list the approximate date of your child's last dental exam.
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Month
-
Day
Year
Date
72. Please list any surgeries, serious illness and/or hospitalizations. Please include date/event.
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73. Please list any CURRENT prescription and/or over the counter medications your child is currently taking. Include name, dose, frequency, and how long they have been taking it. If none, use N/A
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Rows
Name
Dosage
Start Date
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
74. What PRIOR medications has your child taken? Please include the name of the medication, how long it was taken, and why it was discontinued. If none, use N/A.
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Rows
Name
How long it was taken
Reason it was discontinued
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
75.Please, list current Primary Care Provider, and Psychiatric Medication Manager, and contact information.
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76. Describe any pertinent medical/physical information that might inhibit physical activity.
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77. Does your child have any dietary restrictions or follow a special diet? Please describe.
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78. Does your child currently have or ever had any of the following?
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Allergies
Asthma
Chronic Cough
Diabetes (Insulin dependent)
Fainting/Dizziness
Irregular Heartbeat
Heart Problems / Murmurs
Chest Pains
High Blood Pressure
Circulation issues
Bleeding disorder
Frequent Ear Infections
Frequent Illnesses
Tuberculosis
Hepatitis A, B, or C
Bladder/kidney problems or infections
Bedwetting
Headaches
Head Traumas
Seizures
Back problems
Scoliosis
Difficulty Walking / Limping
Joint injuries
Frequent Muscle Cramps
Knee / Hip / Ankle problems
Frequent heartburn
Liver Problems
Anorexia / Bulemia
Frequent Abdominal Pain
Constipation
Diarrhea
Unexpected Weight Loss
Endocrine problems
Menstrual Problems / Heavy Bleeding
Pregnancy
Obesity
Cysts/Tumors
Cancer
Skin Disease
Vision Problems
Hearing Impairment
None
Other
79. Please list all medication, and food allergies your youth experiences. Please, give detailed information about each allergy. If none, please indicate that here.
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80. Does your child carry an inhaler or epi pen?
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81. Does your child have any other medical equipment or devices? Please explain.
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82. Does your child have a service animal or emotional support animal? If so, please specify.
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83. Is your child up to date on immunizations?
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Yes
No
Other
84. Please describe any relevant family medical history (e.g., epilepsy, arrhythmia, etc.), including which family members are affected.
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Education Information
85. What is the highest grade level your child has completed?
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86. Is your child currently attending school?
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Yes
No
Other
87. Please list the name, city, and state of your child's current school.
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88. Briefly describe how your child is performing academically. Include any issues with attendance, any major changes in school performance, and if they are behind on credits.
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89. Does your child have an Individualized Education Plan (IEP) or 504 plan?
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IEP
504 Plan
Neither
Other
90. Has your child ever been suspended or expelled from school? If so, please explain, including dates and the reason for the suspension/expulsion.
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91. Has your child ever received academic or intellectual testing? If yes, please describe including name of test, date given, and tester contact information. Please send in a copy of these tests as part of your application.
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92. Does your child receive any ancillary services through school (speech or occupational therapy, etc.)? Please explain.
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93. Is your child currently employed? Please explain, including how long they have worked there and how many hours per week.
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Insurance Information
Please visit online to see a list of accepted insurances. Private pay options are available, including sliding scale fees for qualifying applicants.
Primary Insurance Company
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Address
Benefits Phone
Group Number
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Policy Number
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Policyholder's Name
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Policyholder's Date of Birth
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Month
-
Day
Year
Date
Employer
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Social Security Number
Secondary Insurance Company. If youth does not have secondary insurance, use N/A.
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Address
Benefits Phone
Group Number
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Policy Number
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Policyholder's Name
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Policyholder's Date of Birth
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Month
-
Day
Year
Date
Employer
Social Security Number
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