Sunny Glen Children's Home San Benito Texas Christian Home Campus Page

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P. O Box 1373 • San Benito Texas 78586
Phone: (956) 399-5356 Fax: (956) 399-3634 • info@sunnyglenchildrenshome.org

Application

Date

Name of Child

Sex:

(M)

(F)

Social Security Number

Birth Date	Place of Birth

Telephone ( )	Religion

Education (grade)	Present School

Referral Source

I give permission for Sunny Glen Children's Home to contact al necessary parties (physician/teacher/etc.) regarding treatment issues, symptoms, behaviors or other information necessary fo the treatment of my child.

Parent / Guardian Name	Date

Signature

Chief Complaint

Present Problems (check all that apply)

Very unhappy Irratable Temper outburst Withdrawn Daydreaming Fearful Clumsy Overactive Slow Short attention span Distractible Lacks initiative Peer conflict Phobic	Impulsive Stubborn Disobedient Infantile Mean to others Destructive Trouble with the law Running away Self-mutilating Head banging Rocking Shy Strange thoughts Runaways	Fire setting Stealing Lying Sexual trouble School performance Truancy Bed wetting Soiled pants Eating problems Sleeping problems Sickly Drug use Suicide talk / danger to self Danger to others

Explain

How long have these problems occured? (number of weeks, months, years)

What happened that makes you seek help at this time? (reason for placement)

Problems perceived to be:	very serious	serious	not serious

What are your expectations of your child in placement?

What changes would you like to see in your child?

What changes would you like to see in yourself?

What changes would you like to see in your family?

Psychosocial History • Current Family Situation

Mother: relationship to child	Natural parent	Stepparent	Relative	Adoptive parent

Occupation

Education

Religion

Child's birthplace	Child's birth date	Child's age

Father: relationship to child	Natural parent	Stepparent	Relative	Adoptive parent

Occupation

Education

Religion

Birthplace	Birth date	Age

Marital History of Parents

Natural parents	married	When	Age

	separated	When

	divorced	When

	deceased	When

Step- parents	married	When

Ic child is adopted:

Adoption source

Reason and circumstances

Age when child first in home	Date of legal adoption

Living Arrangements

Number of moves in child's life	Places	Dates

Does the child share a room with anyone else?	Yes	No

If yes, with whom?

If no, how long has he/she had own room?

Was the child ever placed, boarded or lived away from the family?	Yes	No

Explain

What are the major family stresses at the present time, if any?

What are the sources of family income?

Brothers and Sisters (indicate if step-brothers or step-sisters)

Name	Age	Sex	School or occupation	Grade	Living at home	Drug use	Treatment for drug use

1.

2.

3.

4.

5.

List all other extended family members by their relation to the child who have drug and/or alcohol problems (legal or illegal), history of depresscion, self-destructive behavior or legal problems.

Others living in the home (and their relationship)

Other significant people in child's life

Health of Family Members (excluding child)

Name	Relationship to child	Type of illness	When occurred	Length of illness

1.

2.

3.

4.

Does or did any member of the child's family have any problems with:

Reading	Spelling	Math	Speech

Is there any history in the child's family of:

Mental retardation	Epilepsy	Birth defects	Schizophrenia

If yes, please explain

Child Health Information

Note all health problems the child has had or has now.

	Age		Age

High fevers		Dental problems

Pneumonia		Weight problems

Flu		Allergies

Encephalitis		Skin problems

Meningitis		Asthma

Convulsions		Headaches

Unconsciousness		Stomach problems

Concussions		Accident prone

HiHead injury		Anemia

Fainting		High or low blood pressure

Dizziness		Sinus problems

Tonsils out		Heart problems

Vision problems		Hyperacivity

Hearing problems		Other illnesses, etc.

Ear aches		Explain

Has the child ever been hospitalized (including psychiatric hospitalization)?	Yes	No

If yes, please explain.

Age	How long	Reason

Age	How long	Reason

Has child ever been seen by a medical specialist?	Yes	No

Age	How long	Reason

Age	How long	Reason

Is the child taking any perscription medications?	Yes	No

Age	How long	Reason

Age	How long	Reason

Has the child been tested for:	Hepatitis B	Results

	AIDS	Results

	Other STDS	Results

List all psychiatric diagnoses child has been given

Name of Primary Care Physician

Developmental History

Prenatal-child wanted?	Yes	No

Planned for?	Yes	No

Normal pregnancy?	Yes	No

If mother was ill or upset during pregnancy, explain

Length of pregnancy

Paternal support and acceptance, explain

Birth

Full term?	Yes	No	If premature, how early?

Birth weight	lbs.	oz.

Did mother abuse alcohol/drugs during pregnancy?	Yes	No

Newborn Period

Irritability	Yes	No	How long?

Vomiting	Yes	No	How long?

Difficulty breathing	Yes	No	How long?

Difficulty sleeping	Yes	No	How long?

Convulsions / twitching	Yes	No	How long?

Colic	Yes	No	How long?

Normal weight gain	Yes	No	How long?

Was child breastfed?	Yes	No	How long?

Developmental Milestones

At age which child:

Sat up	Crawled

Walked	Spoke single words

Sentences	Bladder trained

Bowel trained	Weaned

Describe the manner in which toilet training was accomplished

Early Social Development

Relationship to siblings and peers

Individual play	Competitive	Leadership role

Group play	Cooperative	A follower

Describe special habits, fears or idiosyncrasies of the child

Educational History

Name of school

City / State

Dates attended

Grades completed

From

at this school

Preschool

Elementary

Junior High

High School

Type of classes:	Regular	Learning disability	Continuation

	Emotionally handicapped	Opportunity	Other

Did the child skip a grade?	Yes	No

Repeat a grade?	Yes	No

If yes, when and how many years appropriate grade level at present time?

Did child have any specific learning difficulties?	Yes	No

Has child ever had a tutor or other special help with schoolwork?	Yes	No

Does child attend school on a regular basis?	Yes	No

Does child appear motivated for school?	Yes	No

Has child ever been suspended or expelled?	Yes	No

IQ test results	TAKS results

Academic Performance

Highest grade on last report card

Lowest grade on last report card

Favorite subject

Least favorite subject

Does child participate in extracurricular activities?	Yes	No

Explain

In school, how many friends does the child have?	A lot	A few	None

IWhat are the child's aspirations?	Quit school

	Graduate from high school (GED)

	Go to college / trade school

	Military

List child's special interest, hobbies, skills and positive attributes

Criminal History

Has the child had difficulty with the police?	Yes	No

If yes, explain

Has the child ever appeared in juvenile court?	Yes	No

If yes, explain

Has/is the child ever been on probation?	Yes	No

From	To	Reason	Probation Officer

Abuse / Neglect History

Has the child ever been abused?

Physical	Sexual	Neglect	Abandonment

Brief discussion

Additional Comments

Parent / Guardian Name	Date

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