Residential Homes Application NamePhoneEmailChild's nameChild's date of birthChild's genderReason for referral (needs change of environment, needs more structure and supervision, to ensure education/graduation, financial needs, to change educational setting, counseling needs, alternative to boarding school, other)Child's grade in schoolChild's report card gradesABCDFnot sureChild's last school (name and city, state)Does child like schoolyesnonot sureHas child been retained or suspended (if so, when and why)Has child received religious training (if so, describe)Child's parents aremarried to each otherdivorced from each otherseparated from each otherliving togethernever married to each otherOutstanding facts concerning mother and/or father (temperament, relationship with child, etc.)Outstanding facts concerning mother and/or father (temperament, relationship with child, etc.)Child's interests, awards, or positive experiencesDoes child have regular eating habits? (explain)Does child have regular sleep habits? (explain) Child's usual bedtime?List any that apply to the child (and comment) happy, sad, cruel, jealous, aggressive, generous, shyList any that apply to the child (and comment) restless, makes friends easily (older or younger), irritable, talks back, temper tantrums, cries easily, easily discouragedList any that apply to the child (and comment) fights, prefers to play indoors or outdoors, takes turns, shares attention, completes tasks, follows directions, has difficulty communicatingWith which sibling (if any) does the child get along best? Which which sibling (if any) does the child get along least?What is the most effective type of discipline for this child? What is the least effective? Who usually administers discipline?How did you hear about NMCCH? And is there anything else you wish to tell us about this child or this situation?
