Name of person completing application
*
First Name
Last Name
Phone
(###)
###
####
Email
*
Relationship to Child
*
Is this applicant/child currently under managing conservatorship of a State?
*
If yes, what state?
Caseworker's Name
First Name
Last Name
Caseworker's Cell Phone
(###)
###
####
Case Worker's Email
Complete Legal Name of the Child
*
First Name
Last Name
Name the child prefers
First Name
Last Name
Age
*
Birthdate
*
MM
DD
YYYY
Current Grade
*
12
11
10
9
8
7
6
5
4
3
2
1
Race
U.S. Citizen
*
Place of Birth
Hair Color
Birthmarks/Scars
Tattoos/Piercings
Is the Child presently living at home?
If No, Please explain
Reason for placement
Was carried full term? Any issues with delivery?
Has child been made aware of reason for placement and if so, what is their reaction to placement?
Are you aware of any relatives who might object to this placement?
If yes, please explain
Have you ever made an application at another boys home or institution?
If yes, when and where?
Was youth made aware of reason for placement?
Youth’s reaction after being informed the reason for their placement
Who informed the youth of reason for placement?
Legal Guardian/ Father’s Name
First Name
Last Name
Date of Birth
MM
DD
YYYY
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
Monthly Income
Home Phone
(###)
###
####
Business Phone
(###)
###
####
Cell Phone
(###)
###
####
Email
Legal Guardian/ Mother’s Name
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
Monthly Income
Home phone
(###)
###
####
Business Phone
(###)
###
####
Cell number
(###)
###
####
Email
Step-Father’s Name
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
Monthly Income
Home phone
(###)
###
####
Business Phone
(###)
###
####
Cell number
(###)
###
####
Email
Step-Mother’s Name
First Name
Last Name
Home Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Occupation
Monthly Income
Home phone
(###)
###
####
Business Phone
(###)
###
####
Cell Phone
(###)
###
####
Email
Name
First Name
Last Name
Relationship to Student
Home Phone
(###)
###
####
Business Phone
(###)
###
####
Cell Phone
(###)
###
####
Email
Please list all brothers, sisters, step-brothers and step-sisters
Name, Age, Relation, Currently Living With
Father
Mother
Step-Father
Step-Mother
Siblings
Please describe any other significant relationships with family members
Are parents divorced?
If yes, when?
Who has custody?
Can child have contact with both parents?
If no, please explain
Has the divorce or separation been an issue for your child?
If yes, please explain
Any past or current custody battles?
If Yes, please explain
Have either parent remarried?
Has this been an issue with your child?
If yes, please explain
Was your child Adopted?
If yes, when
Age
Where was your child adopted from?
Previous adoption homes?
Please explain any special circumstances leading up to the adoption
Has the adoption been an issue for the child?
If yes, please explain
Does the child know the information of the biological parents?
If yes, please explain
Have the biological parents been involved?
If yes, please explain
What are your child’s current behavior problems?
Has this child ever demonstrated aggressive or violent behavior?
If yes, Please explain
Has this child been involved in delinquent behavior or with the law?
If yes, please explain nature of the problem
Has this child ever talked about, threatened, or attempted suicide?
If yes, please explain
Has your child had any changes in behavior or mood?
If yes, please explain
When did these changes occur?
Has your child discussed any abnormal thoughts?
If yes, please explain
Please describe the history of any specific disorder this child has had or currently has
Child’s special needs
Nervous habits
Sleeping at night
Has this child lied to you?
If yes, how many times?
Has this child used illness to miss school or get out of responsibilities?
If yes, how often?
Has the child ever run away?
If yes, How many times?
Most recent event?
Was the child running away alone or with friends or family?
How long was the child gone?
Did the child call home?
Distance traveled?
Who did the child stay with?
Was the child in illegal activity?
If yes, please explain in detail
What was the reason the child ran away?
Please check all that apply if your child has experienced any of these
Please explain any other behaviors that cause concern
Does the child make friends easily?
If no, please explain
Does the child prefer to be alone?
Are the child’s friends younger, older, or the same age as the child?
Are the child’s friends the same sex or opposite sex?
Has the child recently changed friend groups or stopped hanging out with current friends?
What type of peer groups does your child spend time with?
What are your feelings about the child’s friends?
People outside of the home
School
Religion
Please describe the child’s performance (grades, relationship with teachers, behavior, etc.)
Elementary School
Middle school
High school
Any learning difficulties
Sports or extra-curricular interests
Has the child ever been suspended or expelled?
If yes, when?
Please explain
Name of current school
Phone
(###)
###
####
Current Grade
12
11
10
9
8
7
6
5
4
3
2
1
Still attending?
Last grade completed
12
11
10
9
8
7
6
5
4
3
2
1
What do you perceive as the child’s current academic needs?
Please check any of the following that apply to this child
If you answered yes to any above, please explain
Please list any allergies
Previous Illnesses
Physical or mental handicaps
Check all that appy
Date of last DPT injection
MM
DD
YYYY
History of injuries
If none, indicate none
History of surgeries
If any, When? What? If none, indicate none
List of current medications this child is on and the reasons
Have you ever sought psychiatric for this child?
If yes, please explain in letter circumstances and medications prescribed and attach to this application
Hearing and speech problems?
Vision
Dental
Date of last check-up
MM
DD
YYYY
Medical needs
Date of last physical exam
MM
DD
YYYY
Name of Physician or office
Family history of substance abuse
To your knowledge, is this child sexually active?
Has this child experienced sexual abuse or rape?
Does this child have a history of being sexually aggressive or violent?
Has this child exhibited any sexual identity issues?
Incest
Victim
Offender
None
Rape
Victim
Offender
None
Molestation
Victim
Offender
None
Physical Abuse
Victim
Offender
None
Sexual Perpetration
Victim
Offender
None
Verbal/Emotional Abuse
Victim
Offender
None
Neglect
Victim
Offender
None
Legal Measures Taken
Victim
Offender
None
Have there been any circumstances in the child’s life which have been hard for him to accept?
Have there been any deaths of family or friends that have greatly impacted the child’s life?
What does this child believe the current situation/problem to be?
What are your expectations of placement with Brotherhood Academy?
What do you see as this child’s estimated stay at Brotherhood Academy?
How do you plan to be involved with this child’s growth while at Brotherhood Academy?
What is this child’s perception of being placed with Brotherhood Academy?
What do you see as the goal for this child and the family’s goal for placement with Brotherhood Academy?
Please give any other information about this child and his activities that has caused him to need placement with Brotherhood Academy. (as much detail as possible please)
