Placement Form

Parent/Guardian Name*

First Last

Phone*

Email*

Enter Email Confirm Email

Address*

Street Address City State / Province / Region ZIP / Postal Code

Relationship to Child*

An official copy of the custodial agreement, adoption decree, and/or guardianship paperwork is required.

Child's Information

We are unable to work with children under 12 years of age and who are under the 6th grade.

Child's Name*

First Last

Child's Age*

Please enter a number from 12 to 17.

Child's Grade*

Please enter a number from 7 to 12.

Gender*

Male

Female

Do you know your child's IQ?*

What is your child's IQ?*

Please enter a number from 1 to 180.

How does your child perform academically?*

Does your child have an IEP or 504 plan? (Please explain and provide latest report)*

Explain how your child behaves in school.*

List your child's diagnosis.*

We are unable to work with children who present on the Autistic spectrum, have Reactive Attachment Disorder, or who require high levels of medication.

List your child's medications.*

Has your child ever attempted suicide? (Please explain)*

Has your child ever been hospitalized for reasons related to suicide? (Please explain)*

Does your child self-harm? (Please explain)*

Does your child have health problems or physical restrictions? (Please explain)*

Has your child ever had a head concussion or loss of consciousness? (Please explain)*

Describe your child's "friend group"*

Describe your child's level of social skills (age-appropriate, acts younger, etc.)*

We are unable to work with children who are actively involved in gangs or who have previously participated in gang activity.

Does your child have a history of running away? (Please explain)*

We are unable to provide adequate support and safety for kids who have a history of running away.

Does your child have a desire to change and/or recognize the need to get help? (Please explain)*

List other "outside the home" placements, including the dates your child was in placement.*

How you found us?*

Name

This field is for validation purposes and should be left unchanged.

MSCH Inquiry

Child's Information