NVW Pre-Screen Form Question Title * 1. Basic Information Parent Name: Child Name: Parent Phone: Referral: Question Title * 2. Have you been in contact with an Educational Consultant? Question Title * 3. Age/Gender Age Gender Age/Gender 12 13 14 15 16 17 18 19 20 21 22 23 24 Age/Gender Age menu Male Female Age/Gender Gender menu Other (please specify) Question Title * 4. Potential trip and estimated date of enrollment? Question Title * 5. Medical Concerns Allergies Asthma Encopresis (fecal) or Anuresis (urine) Pre-existing Injury Surgery Overweight Other Explain Inury: Question Title * 6. Does this child take any of the following medications? Topamax or Topamate Tricyclic Antihistamine Lithium Seroquel Risperdal Xanax Please list any side effects or other concerns Question Title * 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? Question Title * 8. Will you want your child to see our (WI) Psychiatrist when they are in our program Yes No Maybe Other (please specify) Question Title * 9. When was the last physical exam that your child had completed? - Date Question Title * 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? Yes No Plan for Physical Question Title * 11. What Substances Have Been Used in the Past Year and How Often? Question Title * 12. Reaction when under stress? Anger Physical Aggression Withdraws Oppositional Drugs Home, School, Other Question Title * 13. Recent Hospitalization/RTC placement? In the last 30 days? Yes No When/Why? Question Title * 14. Propensity for Violence? Yes No If Yes, Why? (triggers, with whom, etc): Question Title * 15. Sexual Boundaries? (paraphilia, perpetration hx, substantiated vs unsubstantiated claims, law enforcement involvement, sexual abuse?) Yes No If Yes, Explain. Question Title * 16. Suicide Attempts or Ideation? (Intensity, how often, plans in place, in the last 6 months?) Yes No If Yes, Explain. Question Title * 17. AWOL History? (how often, how long, how many years has this been happening?) Yes No If Yes, Explain. Question Title * 18. Mental Diagnosis: Trauma RAD/Adopted PDD ADD/ADHD Bi-Polar ODD Anxiety Depression Personal Dis. AODA Other, Explain. Question Title * 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?) Question Title * 20. Psychological testing? Yes No When, where, who? Question Title * 21. Does your child have an IEP? If so, when doe it expire? Yes No Comment Question Title * 22. How does your child feel about coming and who will transport? Willing Resistant Doesn't Know Parent Drop Off Escort Service Other (please specify) Question Title * 23. What, if any, are the thoughts about aftercare plans? No Yes Please explain Question Title * 24. Parent Goals 1. 2. 3. Question Title * 25. How does your family plan to pay for NVW? Primary Family Will Pay Secondary Family Will Help/Pay Insurance Reimbursement American Healthcare Lending Charlie Bessette Scholarship Ohana Foundation Other (please specify) Question Title * 26. What does funding source understand about length of stay? Question Title * 27. Notes: Question Title * 28. Submitted by: DH CL HS AE AS TM Other (please specify) Done