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CHILD APPLICATION

CHILD:

FULL LEGAL NAME_________________________________________________________________________________

AGE ______GRADE_________________DOB_______________________BIRTHPLACE__________________________

SS NUMBER _____________________SEX__________RACE_______________RELIGION________________________

HEIGHT _____________WEIGHT_________ HAIR _______________________EYE COLOR______________________

DISTINGUISHING MARKS____________________________________________________________________________

LAST RESIDED WITH _________________________________RELATIONSHIP_________________________________

ADDRESS________________________________________________________________________________________

HOME PHONE ______________________________CELL PHONE_____________________________________________

LEGAL GUARDIAN _____________________________RELATIONSHIP_______________________________________

ADDRESS ____________________________________________HOME PHONE________________________________

PRIOR PLACEMENTS (Include foster care, hospitalizations, etc.):

Name Address Date

(1) ________________________________________________________________________________________________

(2) ________________________________________________________________________________________________

(3) ________________________________________________________________________________________________

(4) ________________________________________________________________________________________________

DHS OR CPS CUSTODY-________________DATE/S__________________________________________________________

PLACEMENT REASON _______________________________DISCHARGE REASON_______________________________

COURT RECORD ___________________DATE/S _____________________REASON/S_____________________________

CASE WORKER/PO NAME _______________________________________PHONE #_______________________________

REASON____________________________________________________________________________________________

HOW DOES CHILD FEEL ABOUT PLACEMENT AT TIPTON HOME?____________________________________________________________________________________________________

____________________________________________________________________________________________________

PRESENTING PROBLEM: DESCRIBE REASON FOR PLACEMENT AT THE TIPTON HOME.

____________________________________________________________________________________________________

LIST CHILD’S INTERESTS, HOBBIES, ETC. (1)_____________________________________________________

(2)___________________________________________(3)__________________________________________

FAMILY HISTORY: RELATIVES OR OTHER INTERESTED PERSONS

NAME RELATION ADDRESS PHONE

(1)___________________________________________________________________________________________________

(2)___________________________________________________________________________________________________

NAME DOB ADDRESS PHONE

SIBLINGS: (1)__________________________________________________________________________________________

(2)___________________________________________________________________________________________________

(3)___________________________________________________________________________________________________

(4) ___________________________________________________________________________________________________

(5) ___________________________________________________________________________________________________

BIRTH ORDER: ONLY; 1ST; 2ND; 3RD; 4TH; 5TH; 6TH; 7TH;BABY, ADOPTED, TWIN

BIOLOGICAL MOTHER: ________________________________________________________________________ NAME DOB SS#

________________________________________________________________________________________________________________________ ADDRESS HOME PHONE CELL PHONE

________________________________________________________________________________________________________________________ OCCUPATION EMPLOYER

________________________________________________________________________________________________________________________ SALARY WORK PHONE LENGTH OF EMPLOYMENT

IF DISABLED, DECEASED, INCARCERATED, OR UNEMPLOYED GIVE DATES, AGE OF CHILD AT ONSET AND

REASON/S

_______________________________________________________________________________________________________

NAME OF SPOUSE/LIVE IN _________________________________________________________________________________

BIOLOGICAL FATHER: ___________________________________________________________________________ NAME DOB SS#

________________________________________________________________________________________________________________________

ADDRESS HOME PHONE CELL PHONE

________________________________________________________________________________________________________________________

OCCUPATION EMPLOYER

_________________________________________________________________________________________________________________________ SALARY WORK PHONE LENGTH OF EMPLOYMENT

IF DISABLED, DECEASED, INCARCERATED, OR UNEMPLOYED GIVE DATES, AGE OF CHILD AT ONSET

AND REASON/S

_________________________________________________________________________________________________________

NAME OF SPOUSE/LIVE IN __________________________________________________________________________________

FAMILY-OF-ORIGIN PSYCHO/SOCIAL/MEDICAL HISTORY:

MOTHER FATHER SIBLING 1 SIBLING 2 P/M AUNT/UNCLE P/M GRANDMOTHER/FATHER

DRUG USE_________________________________________________________________________________________________

DIVORCE__________________________________________________________________________________________________

SEXUAL ABUSE____________________________________________________________________________________________

MENTAL DISORDER_________________________________________________________________________________________

EDUCATION LEVEL__________________________________________________________________________________________

TEMPERAMENT______________________________________________________________________________________________

COUNSELING_______________________________________________________________________________________________

DIABETES OR TB____________________________________________________________________________________________

HEPATITIS A B C____________________________________________________________________________________________

FINANCIAL: IS CHILD ENTITLED TO ANY AID FROM:

(1) SOCIAL SECURITY ______________________AMOUNT $____________ ______SS#___________________________________

NAME OF BENEFACTOR ______________________________________________________________________________________

(2) VETERANS BENEFITS ____________________AMOUNT $_________________ CLAIM#________________________________

SOURCE NAME______________________________________________________________________________________________

(3)CHILD SUPPORT _________________________AMOUNT $___________________SS#__________________________________

NAME OF BENEFACTOR ______________________________________________________________________________________

(4) OTHER SOURCE OF INCOME __________________________________________AMOUNT $_____________

****I CERTIFY THAT I AM NOT UNDER ANY FINANCIAL OBLIGATION WHILE MY CHILD

IS A RESIDENT AT THE TIPTON HOME THEREFORE, I WILL PROVIDE $0 TOWARDS

THE CHILD’S SUPPORT.

SIGNATURE ______________________________________________DATE____________________________

EDUCATION: USUAL GRADES OF STUDENT [ A B C D F ]

HAS THE CHILD EVER:

REPEATED A GRADE ________ WHICH ONE/S _________________________________________________________________________

BEEN IN SPECIAL ED OR REMEDIAL CLASS? _____________BEEN IN GIFTED OR TALENTED CLASSES _____________

WHEN___________________ BEEN IN SPEECH THERAPY CLASS_____________

BEEN A DISCIPLINE PROBLEM AT SCHOOL ____________IF SO, EXPLAIN _________________________________________________

______________________________________________________________________________________________________________

BEEN SUSPENDED ( ) EXPELLED ( ) IN-SCHOOL DETENTION ( ) SATURDAY SCHOOL ( ) TRUANT ( )

EXPLAIN ______________________________________________________________________________________________________

CURRENT SCHOOL AND ADDRESS ________________________________________________________________________________

PREVIOUS SCHOOL/S: _________________________________________________________________________________

NAME ADDRESS DATES ATTENDED

__________________________________________________________________________________________________

NAME ADDRESS DATES ATTENDED

__________________________________________________________________________________________________

NAME ADDRESS DATES ATTENDED

__________________________________________________________________________________________________

NAME ADDRESS DATES ATTENDED

MEDICAL HISTORY: REGULAR PHYSICIAN ________________________________ADDRESS _____________________________

DO YOU HAVE HEALTH INSURANCE WHICH CARRIES THE CHILD AS A DEPENDENT? Y N

NAME OF INSURANCE ____________________________________________________POLICY#______________________

HAS THE CHILD HAD THE FOLLOWING?

DATE/S DR. & LOCATION/S REASON/S

SERIOUS ILLNESS/S Y N______________________________________________________________________________________

BROKEN BONE/S Y N_______________________________________________________________________________________

HOSPITALIZATION/S Y N ___________________________________________________________________________________

SURGERIES Y N ____________________________________________________________________________________________

IMMUNIZATIONS Y N _______________________________________________________________________________________

A HANDICAP Y N __________________________________________________________________________________________

TETANUS SHOT Y N ________________________________________________________________________________________

DOES THE CHILD HAVE ANY MEDICAL, DENTAL, VISUAL OR PSYCHOLOGICAL PROBLEMS?

Y N IF YES, PLEASE EXPLAIN __________________________________________________________________________________

__________________________________________________________________________________________________________

LIST ANY MEDICATION THE CHILD IS CURRENTLY TAKING OR HAS EVER TAKEN:

NAME: __________________________________REASON__________________________________________________________

DR. WHO PRESCRIBED IT ___________________________________________________________________________________

HOW LONG HAS CHILD BEEN TAKING THIS PRESCRIPTION?_______________________________________________________

NAME:__________________________________REASON_________________________________________________________

DR. WHO PRESCRIBED IT ___________________________________________________________________________________

HOW LONG HAS CHILD BEEN TAKING THIS PRESCRIPTION?_______________________________________________________

NAME: __________________________________REASON__________________________________________________________

DR. WHO PRESCRIBED IT ____________________________________________________________________________________

HOW LONG HAS CHILD BEEN TAKING THIS PRESCRIPTION?_______________________________________________________

NAME: __________________________________REASON__________________________________________________________

DR. WHO PRESCRIBED IT ____________________________________________________________________________________

HOW LONG HAS CHILD BEEN TAKING THIS PRESCRIPTION?_______________________________________________________

IS THE CHILD ALLERGIC TO MEDICATIONS, FOODS, BEE STINGS OR OTHER? (CIRCLE THAN EXPLAIN)

______________________________________________________________________________________________________

DOES THE CHILD WEAR GLASSES/CONTACTS? Y N IF YES, WHEN WAS CHILD’S LAST EXAM?____________

DR. __________________________________ADDRESS________________________________________________________

DOES THE CHILD WEAR BRACES? Y N LAST DENTAL EXAM_________________________________________

DENTIST NAME _________________________ADDRESS____________________________CAVITIES? Y N

HAS THE CHILD ATTENDED COUNSELING? Y N HAD A PSYCHOLOGICAL EVALUATION? Y N

PSYCHOLOGIST NAME AND ADDRESS _______________________________________________________________

__________________________________________________________________________________________________

DOES THE CHILD HAVE ANY TATTOOS? Y N DATE OF EACH ______________________________________________

DONE PROFESSIONALLY OR HOMEMADE? _______________________________________________________________

DOES THE CHILD HAVE OR EVER HAD ANY PROBLEM WITH THE FOLLOWING:

	YES	NO	DESCRIPTION AND DATE OF ONSET
ALLERGIES	______	______	__________________________________________________________
ASTHMA	______	______	__________________________________________________________
DIABETES	______	______	__________________________________________________________
HEART PROBLEMS	______	______	__________________________________________________________
HEARING LOSS	______	______	__________________________________________________________
WHOOPING COUGH	______	______	__________________________________________________________
SEIZURES	______	______	__________________________________________________________
MEASLES	______	______	__________________________________________________________
EAR TROUBLE	______	______	__________________________________________________________
FAINTING SPELLS	______	______	__________________________________________________________
DIPTHERIA	______	______	__________________________________________________________
THROAT TROUBLE	______	______	__________________________________________________________
CHICKEN POX	______	______	__________________________________________________________
MUMPS	______	______	__________________________________________________________
KIDNEY PROBLEMS	______	______	__________________________________________________________
RHUMATIC FEVER	______	______	__________________________________________________________
SMALL POX	______	______	__________________________________________________________
HAY FEVER	______	______	__________________________________________________________
INFANTILE PARALYSIS	______	______	__________________________________________________________
SCARLETT FEVER	______	______	__________________________________________________________
HIGH BLOOD PRESSURE	______	______	__________________________________________________________
HYPERACTIVE/ADHD	______	______	__________________________________________________________
ALCOHOLISM	______	______	__________________________________________________________
AIDS/HIV OR STD’S	______	______	__________________________________________________________
TUBERCULOSIS	______	______	__________________________________________________________
HEPATITIS A B C	______	______	__________________________________________________________
SEXUAL RELATIONS	______	______	__________________________________________________________
ABORTION/S	______	______	__________________________________________________________
INCESTUOUS RELATIONS	______	______	__________________________________________________________
INTRAVENOUS DRUG USE	______	______	DATE OF LAST USE ____________________________
HAS CHILD STARTED HER PERIOD YET?	______	______

DATE OF LAST MENSTRUAL CYCLE ____________________ # OF DAYS ( ) AGE OF ONSET ______________

POSSIBILITY OF BEING PREGNANT? ________ DATE OF LAST INTERCOURSE ____________________________

DESCRIBE CHILD’S SEXUAL PECULLARITIES OR IDEATIONS _______________________________________________

_________________________________________________________________________________________________

HAS THE CHILD USED/OR IS CURRENTLY USING UNPRESCRIBED DRUGS, ALCOHOL, OR ANY

FORM OF TOBACCO? (EXPLAIN_______________________________________________________________________________________

HAS THE CHILD BEEN ABUSED?

PHYSICALLY? ________________________________________________________________________________

EMOTIONALLY? ______________________________________________________________________________

SEXUALLY? ________________________________________________________________________________

SPIRITUALLY? _______________________________________________________________________________

HAS THE CHILD THREATENED SUCIDE? Y N IF YES, HOW MANY TIMES (_______) PLEASE EXPLAIN____________________________________________________________________________________

___________________________________________________________________________________________

WHAT WAS HAPPENING WITH THE FAMILY AT THAT TIME? ________________________________________

____________________________________________________________________________________________

_____________________________________________________________________________________________

HAS THE CHILD RAN AWAY OR THREATENED TO RUN AWAY? Y N

IF YES, HOW MANY TIMES (_______) PLEASE EXPLAIN ______________________________________________

______________________________________________________________________________________________

WHAT WAS HAPPENING WITH THE FAMILY AT THAT TIME? _________________________________________

______________________________________________________________________________________________

This is a list of problems that the child may or may not be having. Please indicate the frequency

of each problem by circling the appropriate number. Rate the following on a 0-10 scale

system: 0=never, 1=rarely, 2-3=seldom, 4-5=occasionally, 6-7=often, 8-9=frequently,

10=always/extremely.

DATE OF ENTRY ___________PERSON/S ANSWERING _________________________________________________

1	AFRAID OF NEW SITUATIONS……	1	2	3	4	5	6	7	8	9	10
2	WORRIES TOO MUCH………………	1	2	3	4	5	6	7	8	9	10
3	SAD OR UNHAPPY MOST OF THE TIME…	1	2	3	4	5	6	7	8	9	10
4	SELF-CENTERED OR STUCK UP…	1	2	3	4	5	6	7	8	9	10
5	POOR PERSONAL APPEARANCE…	1	2	3	4	5	6	7	8	9	10
6	WASTES TIME	1	2	3	4	5	6	7	8	9	10
7	OTHERS TAKE ADVANTAGE OF CHILD	1	2	3	4	5	6	7	8	9	10
8	SHY OR TOO QUIET	1	2	3	4	5	6	7	8	9	10
9	IMMODEST ABOUT BODY, SHOWS OFF	1	2	3	4	5	6	7	8	9	10
10	SETS GOALS TOO HIGH	1	2	3	4	5	6	7	8	9	10
11	DENIES HAVING DONE WRONG	1	2	3	4	5	6	7	8	9	10
12	TELLS THINGS THAT DID NOT OCCUR	1	2	3	4	5	6	7	8	9	10
13	CLINGS TO ADULTS	1	2	3	4	5	6	7	8	9	10
14	RESTLESS SLEEP	1	2	3	4	5	6	7	8	9	10
15	HAS TROUBLE FALLING ASLEEP…	1	2	3	4	5	6	7	8	9	10
16	CRIES OFTEN	1	2	3	4	5	6	7	8	9	10
17	SOILS SELF OR CLOTHING (URINATION OR BOWEL)	1	2	3	4	5	6	7	8	9	10
18	WETS THE BED	1	2	3	4	5	6	7	8	9	10
19	ACTS OLDER THAN ACTUAL AGE	1	2	3	4	5	6	7	8	9	10
20	RESTLESS, OVERACTIVE…	1	2	3	4	5	6	7	8	9	10
21	FEELINGS HURT EASILY…	1	2	3	4	5	6	7	8	9	10
22	ACTS YOUNGER THAN ACTUAL AGE	1	2	3	4	5	6	7	8	9	10
23	POOR SELF-IMAGE	1	2	3	4	5	6	7	8	9	10
24	TAKES CORRECTION POORLY	1	2	3	4	5	6	7	8	9	10
25	BLAMES OTHERS FOR MISTAKES…	1	2	3	4	5	6	7	8	9	10
26	BAD RELATIONS WITH ADULTS…	1	2	3	4	5	6	7	8	9	10
27	HAS DEPRESSED ATTITUDE…	1	2	3	4	5	6	7	8	9	10
28	HAS FREQUENT HEADACHES	1	2	3	4	5	6	7	8	9	10
29	COMPLAINS OF ACHES AND PAINS…	1	2	3	4	5	6	7	8	9	10
30	FEELS DEPRESSED A LOT	1	2	3	4	5	6	7	8	9	10
31	MAKES POOR GRADES IN SCHOOL	1	2	3	4	5	6	7	8	9	10
32	FIGHTS AT SCHOOL…	1	2	3	4	5	6	7	8	9	10
33	DISCIPLINE PROBLEM AT SCHOOL…	1	2	3	4	5	6	7	8	9	10
34	DOES NOT COMPLETE HOMEWORK…	1	2	3	4	5	6	7	8	9	10
35	STEALS AT SCHOOL…	1	2	3	4	5	6	7	8	9	10
36	GETS ANGRY EASILY…	1	2	3	4	5	6	7	8	9	10
37	KEEPS ANGER TO SELF	1	2	3	4	5	6	7	8	9	10
38	DOES AS HE/ SHE PLEASES	1	2	3	4	5	6	7	8	9	10
39	STEALS FROM STORES, ETC…	1	2	3	4	5	6	7	8	9	10
40	BAD RELATIONSHIP WITH OTHER KIDS	1	2	3	4	5	6	7	8	9	10
41	HAS EXPLOSIVE TEMPER TANTRUMS	1	2	3	4	5	6	7	8	9	10
42	BULLIES OTHER CHILDREN	1	2	3	4	5	6	7	8	9	10
43	STEALS AT HOME	1	2	3	4	5	6	7	8	9	10
44	USES PROFANITY	1	2	3	4	5	6	7	8	9	10
45	ABUSES OBJECTS (FURNITURE, ETC.)	1	2	3	4	5	6	7	8	9	10
46	INAPPROPRIATE SEXUAL BEHAVIOR	1	2	3	4	5	6	7	8	9	10
47	USES TOBACCO (SMOKES, CHEW, ETC.)	1	2	3	4	5	6	7	8	9	10
48	USES ALCOHOLIC BEVERAGES	1	2	3	4	5	6	7	8	9	10
49	USES DRUGS (SPECITY_____________________	1	2	3	4	5	6	7	8	9	10
50	GANG INVOLVEMENT/ INTEREST	1	2	3	4	5	6	7	8	9	10
51	LACK OF PARENTAL SUPERVISION	1	2	3	4	5	6	7	8	9	10
52	NEGLECT	1	2	3	4	5	6	7	8	9	10
53	LACK OF ECONOMIC RESOURCES	1	2	3	4	5	6	7	8	9	10
54	EASILY DISTRACTED	1	2	3	4	5	6	7	8	9	10
55	LIKES SCHOOL	1	2	3	4	5	6	7	8	9	10
56	EXHIBITS LEADERSHIP QUALITIES	1	2	3	4	5	6	7	8	9	10
57	RESPONSIBLE, FOLLOWS RULES….	1	2	3	4	5	6	7	8	9	10
58	CONSIDERATE, HELPFUL…	1	2	3	4	5	6	7	8	9	10
59	AFFECTIONATE…	1	2	3	4	5	6	7	8	9	10
60	HAPPY GO LUCKY, PLAYFUL	1	2	3	4	5	6	7	8	9	10
61	ENTERTAINS SELF WELL	1	2	3	4	5	6	7	8	9	10
62	SAD/CRIES	1	2	3	4	5	6	7	8	9	10
63	FEELS USELESS, HELPLESS	1	2	3	4	5	6	7	8	9	10
64	SULKS AND POUTS…	1	2	3	4	5	6	7	8	9	10
65	WITHDRAWN/PERFERS BEING ALONE	1	2	3	4	5	6	7	8	9	10
66	MOODY/EMOTION SHIFT QUICKLY	1	2	3	4	5	6	7	8	9	10
67	NERVOUS, FEARFUL, ANXIOUS	1	2	3	4	5	6	7	8	9	10
68	TOUCHY, RESENTS CRITICISM	1	2	3	4	5	6	7	8	9	10
69	SHOW EMOTION	1	2	3	4	5	6	7	8	9	10
70	BITES NAILS	1	2	3	4	5	6	7	8	9	10
71	GIVES UP EASILY	1	2	3	4	5	6	7	8	9	10
72	ARGUES, CRITICIZES OTHERS	1	2	3	4	5	6	7	8	9	10
73	CURSES, USE ABUSIVE LANGUAGE	1	2	3	4	5	6	7	8	9	10
74	CONS OTHERS/MANIPULATIVE…	1	2	3	4	5	6	7	8	9	10
75	DEMANDS ATTENTION…	1	2	3	4	5	6	7	8	9	10
76	RESENTS DISCIPLINE…	1	2	3	4	5	6	7	8	9	10
77	SCRATCHES, CUTS OR HURTS SELF…	1	2	3	4	5	6	7	8	9	10
78	PLAYS WITH FIRE/ MATCHES…	1	2	3	4	5	6	7	8	9	10
79	DISTORTS THE TRUTH	1	2	3	4	5	6	7	8	9	10
80	CONFUSED, RAMBLED SPEECH	1	2	3	4	5	6	7	8	9	10
81	“BORROWS” WITHOUT PERMISSION	1	2	3	4	5	6	7	8	9	10
82	MAKES UNUSUAL REPETITIVE MOVEMENTS	1	2	3	4	5	6	7	8	9	10
83	NERVOUS HABITS (SPECIFY_____________________)	1	2	3	4	5	6	7	8	9	10
84	HITS, FIGHTS, ATTACKS OTHERS	1	2	3	4	5	6	7	8	9	10
85	THREATENS TO HURT OTHERS	1	2	3	4	5	6	7	8	9	10
86	MAKES FRIENDS EASILY	1	2	3	4	5	6	7	8	9	10
87	PASSIVE, EASILY INFLUENCED…	1	2	3	4	5	6	7	8	9	10
88	WILLING TO SHARE WITH OTHERS	1	2	3	4	5	6	7	8	9	10
89	DEFENDS SELF	1	2	3	4	5	6	7	8	9	10
90	FORMS CLOSE RELATIONSHIPS	1	2	3	4	5	6	7	8	9	10

91	VANDALIZES, DESTROYS OBJECTS	1	2	3	4	5	6	7	8	9	10
92	USES WEAPONS (SPECIFY______________________)	1	2	3	4	5	6	7	8	9	10
93	RUNS AWAY (#_______)…………………………	1	2	3	4	5	6	7	8	9	10
94	SNIFFS PAINTS, SOLVENTS, GASOLINE, ETC…	1	2	3	4	5	6	7	8	9	10
95	SMOKES MARIJUANA	1	2	3	4	5	6	7	8	9	10
96	DEALS DRUGS…	1	2	3	4	5	6	7	8	9	10
97	FORGERY/ THEFT BY CHECK	1	2	3	4	5	6	7	8	9	10
98	AUTOMOBILE THEFT	1	2	3	4	5	6	7	8	9	10
99	IMPULSIVE…	1	2	3	4	5	6	7	8	9	10
100	HAPPY TO COME TO THE TIPTON HOME	1	2	3	4	5	6	7	8	9	10

EXPECTATION/ NEED ASSESSMENT

WHAT ARE YOUR EXPECTATIONS OF THE TIPTON HOME? ______________________________

_____________________________________________________________________________________

WHAT AREAS DOES THE CHILD NEED HELP WITH? _____________________________________

_____________________________________________________________________________________

IF FOR SOME REASON THE CHILD CANNOT STAY AT THE TIPTON HOME PAST THE 30-DAY TRIAL

PERIOD OR LATER, WHO WILL COME TO PICK UP THE CHILD?

NAME_______________________________________________________________________________

ADDRESS____________________________________________________________________________

HOME PHONE #_________________________CELL PHONE # _______________________________

PAGER #_____________________________WORK PHONE # ________________________________

A FRIEND’S #___________________________A NEIGHBOR’S #______________________________

EMAIL ADDRESS_____________________________________________________________________

I HEREBY CONFIRM THAT THE ABOVE STATEMENTS ARE

TRUE TO THE BEST OF MY ABILITY.

______________________________________________________________________

SIGNATURE OF GUARDIAN DATE

_______________________________________________________________________

SIGNATURE OF CHILD DATE

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