Friends Program Application

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Referral Date: Referral Date: / MM / DD YYYY
Who referred you to this program? Or how did you find out about us?
Child's Name: Child's Name: First Last
Address: Address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Grade Level:
Age:
Date: Date: / MM / DD YYYY
Social Security Number:

number only - no dashes or spaces
School District:
Gender:
Special Education Services

Special Education Services IEP 504
Parent or Guardian Name: Parent or Guardian Name: First Last
Phone: Phone: - ### - ### ####
Email:
Preferred Contact Method:

Preferred Contact Method: Phone Text Email
Social Functioning/Personality:
Positive Attributes:
Current Activities/Programs:
Interests/Hobbies
Physical Limitations/Medical Conditions:
Symptomatic Behaviors:
Is there a mental health or behavioral diagnosis? If so, please explain.
Current Suicidal Thoughts:

Current Suicidal Thoughts: Yes No
Recent Suicidal Thoughts:

Recent Suicidal Thoughts: Yes No
Any previous suicide attempts?

Any previous suicide attempts? Yes No
Current Physician:
Current Medications:

Enter N/A if none.
Allergies:

Enter N/A if none.
Difficulty Sleeping?

Difficulty Sleeping? Yes No
Appetite Changes?

Appetite Changes? Yes No
Weight Changes?

Weight Changes? Loss Gain
Alcohol/Drug Use:

Alcohol/Drug Use: Yes No
Experience within the juvenile criminal justice system?

Experience within the juvenile criminal justice system? Yes No
What are three goals you have for your child's behavior?
1. 2. 3.