Residential Admission Application

Confidential Application for RESIDENTIAL SERVICES

AK Child & Family
AK Child & Family understands that the decision to apply for services often comes at a time of stress for families. Our goal is to reduce the stress of this time period by providing ongoing communication with families and facilitating as streamlined of an experience as possible. Upon receiving a referral the Director of Admissions will notify you of its receipt and notify you of the Intake Clinical Therapist who has been assigned to screen and process the referral. If at any point you have questions or concerns about the intake process please do not hesitate to contact the assigned Intake Clinical Therapist (907)346-2101 or the Director of Admissions at (907)348-9262.

In order to ensure that applications are processed as timely as possible the following documents should be submitted along with this application for services:

	Attached	Not Attached
Release of Information Forms (preferred ones are included in this application)
Custody Document (must be Legal document)
Psychological and/or Psychiatric Evaluations
Disposition Report (if applicable)
Discharge Summaries from previous placements/treatments
Copy of School Records (especially IEPs, BIPs and any documentation related to suspensions, detentions or expulsions)
Immunization Records
Master Treatment Plan to Include two most recent reviews
Insurance information (complete attached sheet and provide copy of subscriber's ID, DOB and SSN)
Copy of child's Birth Certificate
Copy of child's Social Security Card
Tribal Enrollment Verification (if applicable)
Most recent physical exam

Upload files here:

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Confidential Application for RESIDENTIAL SERVICES
Please direct questions and completed applications to the AK Child and Family Admissions Department at 4600 Abbott Road, Phone: (907)346-2101/Fax: (907)348-9230 Anchorage AK 99507. Referral email: admissionsoffice@akchild.org
Date Completed*

MonthDayYear
Completed By
Email Address*
example@example.com
Referred Student*
Are Parental Rights Still Intact?*

YesNo
Preferred or Cultural Name
Date of Birth*

MonthDayYear
Date
SS#*
Biological Gender*
Identified Gender
Sexual Orientation
Race*
Ethnicity*
Tribal Affiliation
Preferred Language
Is an interpreter needed?

YesNo
Current Placement*
Current Placement Contact Name and Info*
Release of Information for Current Placement?*

YesNo
Most Current Psychiatric Diagnosis Name and Code*
Please list any recent medical or psychiatric testing that has occurred for this youth in the past year*
Smoking Status
Military Status
Parent's Name*
Phone*
Email
example@example.com
Address
City/State/Zip
Legal Custodian?*

YesNo
Parent's Name
Phone
Email
example@example.com
Address
City/State/Zip
Legal Custodian?

YesNo
Custodian (if not parent)
Phone
Email
example@example.com
Address
City/State/Zip
Household Income (for grant and state reporting)
How did you hear about AK Child and Family?
Please verify that you are human*
Should be Empty:

Confidential Application for RESIDENTIAL SERVICES

Confidential Application for RESIDENTIAL SERVICES