* 1. Basic Information

* 2. Have you been in contact with an Educational Consultant?

* 4. Potential trip and estimated date of enrollment?

* 5. Medical Concerns

* 6. Does this child take any of the following medications?

* 7. What medications will this child be taking on the date of enrollment?
How many of each medication will they have on their enrollment date?

* 8. Will you want your child to see our (WI) Psychiatrist when they are in our program

* 9. When was the last physical exam that your child had completed?


* 10. If your child has had a physical within the past two months, will his/her Dr. sign our medical clearance form? If he/she hasn't had a physical within the last two months, how can he/she be medically cleared to enter our program?

* 11. What Substances Have Been Used in the Past Year and How Often?

* 12. Reaction when under stress?

* 13. Recent Hospitalization/RTC placement? In the last 30 days?

* 14. Propensity for Violence?

* 15. Sexual Boundaries? (paraphilia, perpetration hx, substantiated vs unsubstantiated claims, law enforcement involvement, sexual abuse?)

* 16. Suicide Attempts or Ideation? (Intensity, how often, plans in place, in the last 6 months?)

* 17. AWOL History? (how often, how long, how many years has this been happening?)

* 18. Mental Diagnosis:

* 19. Describe the family dynamics. (Adoptive parents or biological? Open or closed adoption? How open? Siblings and relationship with them? Any notable history with family members?)

* 20. Psychological testing?

* 21. Does your child have an IEP? If so, when doe it expire?

* 22. How does your child feel about coming and who will transport?

* 23. What, if any, are the thoughts about aftercare plans?

* 24. Parent Goals

* 25. How does your family plan to pay for NVW?

* 26. What does funding source understand about length of stay?

* 27. Notes:

* 28. Submitted by: