Clone of Clone of Sunshine Acres

Sunshine Acres
CHILDREN'S HOME
This application must be completed in its entirety and returned to Sunshine Acres before the child can be considered for placement.
Name person filling out this application
Relationship to child
Date

MonthDayYear
Date
I hereby request that Sunshine Acres consider providing services to my family and the child named below. All information provided is accurate to the best of my knowledge. I understand that any deliberate false information is grounds for denial into the program.
Signature of legal guardian

Clear
Signature of person completing the application if different

Clear
How did you come to know about Sunshine Acres
Last Name
First Name
Nickname
Middle Name
Place of Birth
Race
Religion
Gender at Birth

MaleFemale
Social Security #
DOB
Current Age
Current Grade Level
Street
City
State
Zip
County
Legal Guardian
Relationship to Child
Relationship to Child

AdoptedNaturalOther
Email Address
example@example.com
Street
City
State
Zip
County
Home Ph.#
Work Ph.#
Cell Ph.#
With whom is the child living?
Please check all reasons that apply to why Sunshine Acres would be of help to you and your child:

I am experiencing homelessnessI have severe medical conditionsI am facing incarcerationI lack sufficient financial resourcesI am unemployedMy child has behavioral challengesI do not have a vehicleI need to therapy/rehabOther

Education(List all schools child has attended starting with the most recent.)

	Grade Level	School Name and Address	Phone Number	Status: IEP, Spec Ed.
1.
2.
3.

Out of Home Placements (Residential Treatment Facilities/Psychiatic Hospitalization's/DCS/Relative Placement.)

	Dates	Name of Facility	Phone Number	Reason for placement	Reason for Termination
1.
2.

Court Involvement( Are there any pending court matters involving your child ?

NoYes (please explain)
Department of Child Safety (Is your family currently or previously involved in any capacity with DCS or CPS?)

NoYes (please explain, including length of time.)

Family Information

	Biological Father	Biological Mother	Previous placement and relationship to child if diffrerent than parent:
Full Name
Birthday
Responsiveness
Current Address
Social Security#
Marital Status

Child's Siblings

	Name	Birth Date	Age
1.
2.
3.
4.
5.
6.

Unapproved Contacts

	Name	Relationship to child
1.
2.

Emergency contacts

	Name	Relationship to child	Phone Number
1.
2.
3.
4.

Person financially responsible for the child
Relationship to child

Financial

	$
Parent/ guardian wages monthly
Child support monthly
Social security monthly
Other income monthly
Total monthly income

Childhood Stressors

	Yes	No
Has the child ever lived with an adult family member who has intimidated or threatened them? (Includes often swearing at, insulting, putting down, humiliating, or fear of being physically hurt)
Has the child ever been physically abused by an adult or household member? (Includes often being pushed, grabbed slapped, or had something thrown at them, or been hit so hard there were marks or injuries)
Has the child ever been sexually abused? (Includes being touched or touching others in a sexual way, try to or actually had intercourse)
Has the child often had feelings that they were not loved, important, or special or that the family was not close or supportive?
Were there times the child did not have enough to eat or had caregivers who were not able to care for them, get them medical attention, or protect them?
Were the child’s parents divorced or separated?
Has the child ever witnessed adult violence in the home? (Includes someone being pushed, grabbed, hit repeatedly,or threatened with a weapon)
Has the child ever lived with someone who had a problem with alcohol or drugs?
Has the child ever lived with anyone who was mentally ill, suicidal, or depressed?
Has the child lived with someone who has been to jail or prison?
Has the child experienced the death of a close family member?
Has the child experienced financial stress, poverty, homelessness, or frequent moves?
Has the child experienced adoption, out of home placements, or court involvement (including DCS or CPS)?

School Functioning YN

	Past	Present	Never	Describe
Not getting good grades in school
Not doing homework
Difficulty with learning
Disturbs others in school
Gets into fights at school
Skips school / truancy
In-school suspensions
Out of school suspensions/expulsions

Emotional Functioning YN

	Past	Present	Never	Describe
Cries easily / often
Unusually long temper tantrums
Moods change quickly / drastically
Easily frustrated
Easily angered
Basically unhappy
Feels/complains no one loves him/her
Feeling anxious
Worries more than others
Feeling lonely
Wishing he/she were dead
Hurts self on purpose (i.e. cutting)
Feeling down or depressed
Not motivated to do anything
Stuffing anger
Exploding with anger
Suicidal thoughts / attempts
Has nightmares
Often confused / in a daze
Frequent daydreams
Behaves like the opposite sex
Sees or hears things that others don’t
Night or day wetting
Soiling or plays with excrement
Trusts new people too easily

Self Esteem

	Past	Present	Never	Describe.
Self-critical / perfectionistic
Feels worthless or inferior
Self-body image problems
Weight problems
Poor hygiene

Hyperactivity

	Past	Present	Never	Describe
Can’t sit still / squirmy
Acts without thinking
Doesn’t finish things
Easily distracted / short attention span
Easily distracted / short attention span

Conduct Symptoms

	Past	Present	Never	Describe
Lies
Steals
Runs away
Gang involvement
Being arrested or detained by police
Using drugs
Using alcohol
Dealing drugs
Destruction of property
Setting fires
Shows cruelty to animals
Physically/sexually acting out w/others
Inappropriate sexual behaviors
Gets into more trouble than others of same age
Denies mistakes / blames others
Picks on other children
Disobedient / or obeys resentfully
Is disrespectful to parents
Has difficulty getting along with other adults / authority figures
Pornography
Sexually active

Peer Relations

	Past	Present	Never	Describe
Provokes fights / quarrelsome
Gets into others’ personal space
Feels others are out to get him / her
Threatens others
Would rather be alone than w/others
Not making or keeping friends
Having friends who are a bad influence
Is picked on by other children
Acts younger than actual age
Doesn’t get along well with siblings

Coping need

	Past	Present	Never	Describe
Coping with physical abuse
Coping with a family member’s drinking / drug use
Coping with emotional abuse
Coping with sexual abuse
Coping with feelings of being adopted
Dealing with a break-up
Difficulty handling the death of someone close to him/her
Loss of an important relationship due to move or death
Coping with a divorce of parents /guardians

Prosocial Behaviors

	Past	Present	Never	Describe
Makes and maintains friendships
Expresses thoughts or feelings appropriately
Feels guilty for doing wrong
Generally cooperative with adults
Shows Leadership Skills

Start of Grief/loss History
Name of deceased
Relationship to child
Did the child live with the deceased
Date of death

MonthDayYear
Date
Cause of death
Was the death sudden
Did the child witness the death
Did the child attend the funeral
End of Grief/loss History
Substance Use/Exposure

Type a question

	Past	Present	Age 1st Use	Last Use	Treatment Facility/Dates
Service Quality
Cleanliness
Responsiveness
Friendliness

Start of Mental Health Information
PsychiatristPrescriber
CounselorTherapist
Diagnosis
End of Mental Health Information

Mental Health Information

	Past/Current Medication	Dosage	Start Date	End date	Reason Perscribed	Prescibing Doctor	Side Effects
1.
2.
3.
4.

Start of Medical Information
Primary Care Physician Name Number
Food Allergies
Dentist Name Number
Medication AllergiesAdverse Drug
GlassesContactsHearing Aids
Other Allergies
History of Hospitalizations
Date of Last Dental Appointment

MonthDayYear
Date
Date of Last Physical

MonthDayYear
Date
History of Operations
Serious Illnesses or Injuries
History of Eye Surgery
Insurance Policy Number Company
Medical Diagnosis

Medication need

	Past/Current Medication	Dosage	Start Date	End Date	Reason Prescribed	Prescribing Doctor	Side Effects
1.
2.
3.
4.

Recurring Health Problems YN need

	Yes	No	If yes, Please explain
Nausea
Diarrhea
Dizziness
Persistent cough
Passing out / fainting
Urinary discomfort
Difficulty breathing
Constipation
Vomiting
Unusual sweats or chills
Self-induced vomiting
Severe dry mouth
Persistent sore throat
Bed wetting
Poor appetite
inappropriate defecation
Sleep disturbances
Stomach aches
Facial or muscle twitching/jerk
Recurring pain
STDs
Bleeding anywhere (mouth, urine, stool)

End of Medical Information

Past/Current Health Conditions Y/N need

	Yes	No	If Yes, please give an approximate Date and indicate if diagnosed by a doctor
Migraine headaches
Sinus trouble
Asthma
Rheumatic fever
Whooping cough
Valley fever
Mononucleosis
Anemia
Hepatitis (if yes indicate type, treatment and duration)
Hernia
Heart murmur
Kidney problems
Eczema
Scoliosis/spine trouble
Broken bones, sprains, dislocations
Eating disorder
Mumps
Measles
Chicken pox
Ear infections
Tubes in ears
Blow to the head (Head trauma)
Seizures or convulsions
Difficulty gaining weight
Recent weight loss/gain

Monther During Pregnancy

	Yes	No	Child Development
Receive prenatal care
Drink alcohol
Use any illegal drugs
Use any medication
Exposed to domestic violence
Inadequate nutrition
Experienced homelessness
Experienced medical problem
Healthy problems
Birth complicatons
Normal birth weight
Birth comcations
Congenital problem
Drug addicted at birth

Child Development need

	Yes	No
Sat up by age 1
Crawled by 18 months
Walked by age 3
Talked in real words by age 3
Fed self with a spoon by age 3
Became completely toilet trained by age 5
Talked in sentences by age 5
Learned to ride a tricycle by age 5
Evaluated for failure to thrive
Evaluated for development delays
Diagnosed with autism
Diagnosed with learning disabilities
Had difficulty with speech
Unusually sensitive to touch

Family history

	Yes	No	If yes, please explain which family member
Heart problems
Thyroid problems
Asthma
Kidney Disease
Sinus/allergy problems
Epilepsy
Addictions/substance abuse
Arthritis
Stroke
Cancer
High/low blood pressure
Tuberculosis
Diabetes
Immune condition
Nervous breakdowns
Convulsive disorders
Depression
Emotional problems

Sunshine Acres
AUTHORIZATION TO EXCHANGE INFORMATION
Childs Name
I authorize Sunshine Acres Children's Home to exchange information with:
Phone
Name of Most Recent School
Fax
Address

Address

Street Address Line 2

City StateState / Province

Zip
INFORMATION TO BE DISCLOSED

MET Evaluation ReportIndividual Education Report (IEP)504 PlanCopy of Immunizations RecordCopy of Birth CertificateTest Results/AIMS ScoresTest Results/AIMS ScoresCurrent Report CardAttendance RecordOther
PLEASE RELEASE THE INFORMATION TO:Academic Services Department academics@sunshineacres.orgSunshine Acres Children’s Home Fax: 1-866-491-53803405 N. Higley Road Phone: 480-981-4112Mesa, Arizona 85215-9741

Acknowledgment
PURPOSE OF DISCLOSURE
I understand that I may revoke this authorization at any time in writing, except to the extent that action based on this authorization has already been taken. This release will expire on year from today or upon the client leaving Sunshine Acres Children's Home.
Date

MonthDayYear
Date
Signature of ParentLegal Guardian

Clear
Date

MonthDayYear
Date
Signature of Witness

Clear
Providing a loving, wholesome, Christian home for children since 1954
Sunshine Acres
RELEASE OF INFORMATION
DOB
I authorize the exchange of records and information, including those which may contain confidential HIV/AIDS related information, confidential communicable disease related information, information relating to mental health and/or alcohol/drug use. I understand that there is potential for information disclosed, as a result of this release/authorization, to be re-disclosed by the recipient and therefore no longer protected by the HIPAA Privacy Regulation. Phone
Name of AgencyPerson
Fax
Address

Address

Street Address Line 2

City StateState / Province

Zip
INFORMATION TO BE DISCLOSED

Type option 1Type option 2Type option 3Type option 4Type option 5Type option 6Type option 7Type option 8Other
PURPOSE OF DISCLOSURE

Continuity of care
PLEASE RELEASE THE INFORMATION TO Academic Services Department (academics@sunshineacres.org) Sunshine Acres Children’s Home Fax: 1-866-491-5380 3405 N. Higley Road Phone: 480-981-4112 Mesa, Arizona 85215-9741

Acknowledgment
Signature of ParentLegal Guardian

Clear
Date

MonthDayYear
Date
Signature of Witness

Clear
Date

MonthDayYear
Date
Should be Empty:

Sunshine Acres

CHILDREN'S HOME

Start of Grief/loss History

End of Grief/loss History

Substance Use/Exposure

Start of Mental Health Information

End of Mental Health Information

Start of Medical Information

End of Medical Information

Sunshine Acres

Sunshine Acres

RELEASE OF INFORMATION