Teen Sentinels

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GENERAL INFORMATION ABOUT YOUR SON
Patient/Student Name*
DOB*
Age*
Social Security Number*
Height*
*
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*
SUICIDAL
Within the last calendar year
Has 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?*
VIOLENCE
Is 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
MEDICAL
List 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?*
LEGAL
Has 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
SCHOOLING
What 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
THERAPY
Has your son been in counseling or therapy?*
- Yes
- No
Please list any diagnosis*
SEXUAL
Is 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
HEALTH
Are 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
MISC
Does 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*

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Teen Sentinels

GENERAL INFORMATION ABOUT YOUR SON

SUICIDAL

VIOLENCE

MEDICAL

LEGAL

SCHOOLING

THERAPY

SEXUAL

HEALTH

MISC