Submit button located at bottom of form GENERAL INFORMATION ABOUT YOUR SONPatient/Student Name* DOB* Age* Social Security Number* Height* inch* Weight* Birth Mothers Name* Birth Fathers Name* Guardian's Full Name* Parents/Guardians Phone Number* Parents/Guardians Email Address* Relationship of the Guardian (Aunt, Grandparent, foster parent, etc.)* Are the Guardians divorced* Yes No Who has custody of your son* Is your son adopted* Yes No Where has your son been living* If one Guardian is sending your son to Liahona Academy, is the other Guardian supportive* Yes No Guardian's Address* Guardian's City* Guardian's State* Guardian's Zip* What is the source of funds used to pay for treatment?* California Department of Education Funding California Adoption Assistance Health Insurance Coverage Private Pay Verification of BenefitsPolicy Holder's Name Relationship to Patient Policy Holder Phone Policy Holder DOB MM slash DD slash YYYY Employer of Policy Holder Insurance Company Insurance Co Phone (the number on the back of your insurance card) ID Group ID Notes I understand that Liahona Academy for Youth is an Out-of-Network Provider for all medical insurance providers and any insurance claims submitted by Liahona Academy for Youth will be done so under the Out-of-Network provision of your medical insurance coverage. SUICIDALWithin the last calendar yearHas your son been suicidal?* Yes No Any verbal expressions of suicide?* Yes No Any physical harm to self? (Such as cutting, eating disorder, etc.)* Yes No Any suicide attempts?* Yes No If your son went to the hospital for any of these conditions, what did the Doctor’s note indicate? Was this an actual suicide attempt or was it attention seeking behavior?* VIOLENCEIs your son violent with any other kids, siblings, or property?* Yes No Is your son violent with Parents/Guardians?* Yes No Is your son violent with Authority?* Yes No Has your son run away or attempted to run?* Yes No Does your son come and go as he wants and acts like nothing has happened?* Yes No Does your son take off and the police have to find and bring him back?* Yes No Has your son ever been physically abused?* Yes No MEDICALList all medications, including frequency and quantity if your son takes medications* Is your son psychotic, schizophrenic, autistic, Asperger’s? If yes, please explain* Yes No Does your son have any seizures, convulsions or epilepsy?* Yes No Does your son have diabetes?* Yes No Is your son allergic to any medications? If yes, please list them.* Yes No Does your son have any self-medicating issues?* Yes No Does your son use alcohol or marijuana? If yes, is it excessive?* Yes No Has your son been diagnosed with Fetal Alcohol Syndrome or has your son had any prenatal exposure to drugs?* Yes No Are there any other drug history?* LEGALHas your son been in trouble with the law? (Give details)* Yes No Has your son ever been arrested?* Yes No Has your son ever been on probation?* Yes No Has your son had any Court dates?* Yes No SCHOOLINGWhat is your son’s last grade finished?* What School has your son been attending?* Has your son dropped out of school?* Yes No Has your son been expelled from school?* Yes No Has your son been failing school?* Yes No What is your son’s reading level?* Does your son require any additional help in school?* Yes No Does your son have an IEP or 504 plan? If yes, what subjects?* Yes No Does your son have an IQ below 85?* Yes No If Yes, IQ below 85 THERAPYHas your son been in counseling or therapy?* Yes No Has your son been admitted into any other treatment programs?* Yes No (if Yes, please name the programs) Has your son attempted to run from other treatment programs?* Yes No (if Yes, please name the programs) Please list any diagnosis* SEXUALIs your son sexual active?* Yes No Does your son have a boyfriend or girlfriend or lots of partners?* Yes No Has your son experienced any sexual deviancy, porn, or inappropriate behavior with another child?* Yes No Does your son have any inappropriate sexual behavior on the internet or social media?* Yes No Has your son ever been sexually abused?* Yes No Has your son ever been the perpetrator of sexual abuse?* Yes No HEALTHAre there any allergies or food allergies?* Yes No Does your son have any problems with bladder control?* Yes No Does your son have any problems with bed wetting?* Yes No Does your son have any other medical problems? (i.e. brain injury, epilepsy, asthma, broken bones, etc.)* Yes No MISCDoes your son have any history of arson?* Yes No If your son is over 185 lbs., is he athletic or a Couch Potato?* Yes No What activities does your son enjoy?* Does your son have any hobbies or interests?* Does your son have any physical limitations?* Anything else we should know about your son*
