SHILOH HOME, INC

1 Admission Application Confidential to SHILOH House Date: Start Date: Anticipated Length of Placement: Paying Agent Name: DOB: Place of Birth: Referring County Program Medicaid #: Social Security #: Reason for placement: Physical Description of child: Sex: Weight: Height: Hair Color: Eye Color: Distinguishing Features: Additional Insurance/Group #: Religious Affiliation: Ethnicity: Hispanic-Latino Non-Hispanic or Latino Race: American Indian or Alaskan Native Asian Black or African American White Native Hawaiian or other Pacific Islander Other Head of Household (Name): M F Household receives SSI/SSDI?

2 Y N Number of People in Household Income Range $10,000-$25,000____25,000-40,000_____Abo ve 40,000_____ Household information is not mandatory; however it is confidentially used for billing, grant-writing and fundraising efforts for SHILOH House. Household is defined by the primary caretaker and intended permanent placement option. Regular Education: Special Education: Current IEP: Y N Current Grade Last School Attended/Address: Expelled? Y N Reasons: Client been suspended: Y N Currently has unexcused absences: Y N Currently passing classes: Y N Mother s Name: Home #: Cell #: Address: City: State: Zip: Marital Status: Email: Father s Name: Home #: Cell #: Address: City: State: Zip: Marital Status: Email: Containment Information: County Caseworker: Phone: Email: After Hours DHS Emergency Contact and Phone: Probation Officer: Phone: Email: : Phone: Email.

3 Doctor: Address Phone #: Date of Last Physical Dentist: Address Phone #: Date of Last Visit Eye Doctor: Address: Phone #: Date of Last Visit Therapist: Address: Phone #: Date of Last Session: List any medical problems: , seizures, asthma, allergies, diabetes, heart disease, respiratory illness, drug reaction: Critical Information: _____ Admission Application Confidential to SHILOH House Are there any present signs of illness, symptoms of abuse or presence of vermin: Describe behaviors: such as suicide attempts, runaway, violent outbursts, depression, stealing, fire setting, excessive crying, or enuresis: Court Date: Judge Division Other Appointments/Dates: Previous Placements (starting with most recent): Name Phone: Address: Dates: From: To: Name: Phone: Address: Dates: From: To: Approved contacts other than previously listed above: Name of Contact Relationship Phone Number Type of Contact (phone, visit or both) All information included in this application is accurate and complete to the best of my knowledge.

4 I received a copy of parent and HIPAA information. Parent/Legal Guardian Signature Date Temporary Custodian/Caseworker Date Date Parent/Legal Guardian Date Temporary Custodian/Caseworker Date Date Staff Conducting Intake Date 3/23/15 Admission Document Requirements and Emergency Contacts Confidential to SHILOH House Client Name: Documentation Required at Intake The following documents and/or information must be provided within 10 days of admission to the SHILOH House Day Treatment program: 1. Individual Education Plan (IEP) (if applicable) 2. Immunization Records 3. Copy of health insurance card 4. Copy of Social Security Card The following documents and/or information must be provided within 30 days of admission to the SHILOH House Day Treatment program: 1. Proof of Physical (within the last 12 months) 2.

5 Copy of Birth Certificate 3. Copy of Youth s Identification Card (if applicable) Emergency Contact The following person(s) should be contacted in case off an emergency and/or in case I am not available: 1. Phone Number 2. Phone Number 3. Phone Number Parent/Legal Guardian Signature Date Staff Signature Date Transportation Information and Parent/Client Responsibilities Confidential to SHILOH House SHILOH House provides transportation as a convienence to our clients and maintains the right to change, modify, revoke or suspend the service when deemed necessary. SHILOH House provides transportation to and from the Day Treatment program within a specified catchment area (the current catchment area will be discussed at intake). This does not mean that if you do not reside within this catchment area we cannot provide services; but we must then discuss and determine an appropriate transportation arrangement.

6 Pick up and drop off occurs as close to your home as possible, though at times, we may need to negotiate pick up and drop off locations. We will do our best to determine a transportation arrangement that meets everyone s needs. However, transportation plans are subject to change at times necessary to accommodate Day Treatment participants. Parent/Guardian is responsible for calling SHILOH House if your child is sick or not attending the program for any reason you might excuse them. We appreciate a direct call to our van drivers, followed by a call to your assigned clinician and the school. In addition , if your child is running late we appreciate a call to our drivers as we may be able to wait or make other arrangements to make a connection. If your child purposely or for other non-purposeful reasons, misses the SHILOH House van transport, SHILOH House is not obligated to make a second run in order to pick up your child.

7 Your child, if age approproate, is expected to find another means to attend the program via RTD or other arrangements you have set up. Is child appropriate for RTD? Yes _____ No _____ Does child need assistance learning RTD routes to/from SHILOH House? Yes _____ No _____ If your child does not adhere to safety while in our vans they can be denied the privilege of riding in our vans for a determined amount of time, not to exclude permanent revocation of the privilege. Client Name: Client Address: Parent phone number: _____ Client Name Date Parent/Guardian Signature Date Staff Signature Date Transportation plan is determined by Director, Program Supervisor and Parent For Internal Use Only Day Treatment Program Releases Confidential to SHILOH House Physical Management Authorization I give SHILOH House and its authorities permission to physically manage my child in the event that he/she poses a danger to himself/herself and/or others and will be used only as a last resort.

8 I understand that the CPI method of therapeutic crisis intervention will be used. I certify to the best of my knowledge that my child does not have a medical condition that would be a threat to the health of my child during a physical management. I have received a copy of the physical management policy. Yes _____ No _____ Event Participation Release As a provider of treatment services, SHILOH House protects the confidentiality of its clients with exceptions being identified at admission. SHILOH House offers events where clients participate in such activities as holiday parties, picnics, public sporting events, SHILOH House community fundraising events and community entertainment activities. Community members/media may be in attendance of any/all of these events. My child has permission to participate in the events/activities listed above. Yes _____ No _____ Photograph Release Photographs may be taken at some events or outings.

9 These photos may be shared with community members for the purpose of fundraising, community education/outreach and/or exclusively used within SHILOH House. In addition, clients may be photographed with other clients and/or staff at these events. I give my permission for my child to be photographed and for the photographs to be used for purposes stated above. Yes_____ No_____ Recreational Activities I give permission for my child to participate in both onsite and offsite recreational activities during placement at SHILOH House. Activities may include: riding bicycles, camping, Tae Kwon do, walks, fishing, weight lifting, backpacking, snowshoeing, swimming, yoga and recreational sports (individual/team). Yes _____ No _____ Sex Education I give permission for my child to participate in on-going classes related to sex education and sexually transmitted diseases. Yes_____ No _____.

10 Internet Release I give permission for my child to access the internet during he/her stay at SHILOH House. I understand that all youth are monitored by staff and all computers have parental controls to help ensure that inappropriate sites are not accessed. Yes _____ No _____ Travel Release I give permission for my child to travel to events/outings, etc. with authorities of SHILOH House. I also hereby release SHILOH House of any and all liability in the event injuries are sustained. Yes _____ No _____ I have received a copy of the family grievance procedure and the family letter. Yes_____ No _____ Parent/Guardian Signature Date Staff Signature Date Day Treatment Medication Release and Agreement Confidential to SHILOH House I give my permission for SHILOH House and its authorities to obtain medical treatment for my child _____ in the event of a medical emergency.