Teen Sentinels
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GENERAL INFORMATION ABOUT YOUR SON
Patient/Student Name
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DOB
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Age
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Social Security Number
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Height
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Weight
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Birth Mothers Name
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Birth Fathers Name
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Guardian's Full Name
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Parents/Guardians Phone Number
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Parents/Guardians Email Address
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Relationship of the Guardian (Aunt, Grandparent, foster parent, etc.)
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Are the Guardians divorced
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Yes
No
Who has custody of your son
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Is your son adopted
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Yes
No
Where has your son been living
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If one Guardian is sending your son to Liahona Academy, is the other Guardian supportive
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Yes
No
Guardian's Address
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Guardian's City
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Guardian's State
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Guardian's Zip
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SUICIDAL
Within the last calendar year
Has your son been suicidal?
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Yes
No
Any verbal expressions of suicide?
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Yes
No
Any physical harm to self? (Such as cutting, eating disorder, etc.)
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Yes
No
Any suicide attempts?
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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?
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VIOLENCE
Is your son violent with any other kids, siblings, or property?
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Yes
No
Is your son violent with Parents/Guardians?
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Yes
No
Is your son violent with Authority?
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Yes
No
Has your son run away or attempted to run?
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Yes
No
Does your son come and go as he wants and acts like nothing has happened?
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Yes
No
Does your son take off and the police have to find and bring him back?
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Yes
No
Has your son ever been physically abused?
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Yes
No
MEDICAL
List all medications, including frequency and quantity if your son takes medications
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Is your son psychotic, schizophrenic, autistic, Asperger’s? If yes, please explain
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Yes
No
Does your son have any seizures, convulsions or epilepsy?
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Yes
No
Does your son have diabetes?
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Yes
No
Is your son allergic to any medications? If yes, please list them.
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Yes
No
Does your son have any self-medicating issues?
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Yes
No
Does your son use alcohol or marijuana? If yes, is it excessive?
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Yes
No
Has your son been diagnosed with Fetal Alcohol Syndrome or has your son had any prenatal exposure to drugs?
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Yes
No
Are there any other drug history?
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LEGAL
Has your son been in trouble with the law? (Give details)
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Yes
No
Has your son ever been arrested?
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Yes
No
Has your son ever been on probation?
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Yes
No
Has your son had any Court dates?
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Yes
No
SCHOOLING
What is your son’s last grade finished?
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What School has your son been attending?
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Has your son dropped out of school?
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Yes
No
Has your son been expelled from school?
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Yes
No
Has your son been failing school?
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Yes
No
What is your son’s reading level?
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Does your son require any additional help in school?
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Yes
No
Does your son have an IEP or 504 plan? If yes, what subjects?
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Yes
No
THERAPY
Has your son been in counseling or therapy?
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Yes
No
Please list any diagnosis
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SEXUAL
Is your son sexual active?
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Yes
No
Does your son have a boyfriend or girlfriend or lots of partners?
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Yes
No
Has your son experienced any sexual deviancy, porn, or inappropriate behavior with another child?
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Yes
No
Does your son have any inappropriate sexual behavior on the internet or social media?
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Yes
No
Has your son ever been sexually abused?
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Yes
No
Has your son ever been the perpetrator of sexual abuse?
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Yes
No
HEALTH
Are there any allergies or food allergies?
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Yes
No
Does your son have any problems with bladder control?
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Yes
No
Does your son have any problems with bed wetting?
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Yes
No
Does your son have any other medical problems? (i.e. brain injury, epilepsy, asthma, broken bones, etc.)
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Yes
No
MISC
Does your son have any history of arson?
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Yes
No
If your son is over 185 lbs., is he athletic or a Couch Potato?
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Yes
No
What activities does your son enjoy?
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Does your son have any hobbies or interests?
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Does your son have any physical limitations?
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Anything else we should know about your son
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