Online Application Residential Application Your name and contact info Child's name Child's date of birth Child's gender Child's social security # Reason 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 school Child's report card grades A B C D F not sure Child's last school (name and city, state) Does child like school yes no not sure Has child been retained or suspended (if so, when and why) Does child receive Special Education services yes no not sure What is child's learning ability below average average above average Has child received religious training (if so, describe) Child's parents are married to each other divorced from each other separated from each other living together never married to each other Outstanding 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 experiences Has child had experience with drugs, liquor, sex, tobacco, lying, stealing, running away? (if so, please describe) Child's emotional / mental condition good fair poor Is child on medication? (if so, type and reason) Child's present physical condition (healthy, handicaps, describe) Has child had recent doctor exams (dental, physical, hearing, vision). Please list doctor's names, city and state, type of exam, and date In relation to other children of the same age, child's development has been below average average above average Please give approximate ages that child sat alone, crawled, walked, was toilet-trained, spoke words, and spoke in sentences Was mother's pregnancy with this child normal, full-term, natural delivery? any complications? Please describe. Was mother on drugs or medication during this pregnancy (if so, what kind) Did mother drink heavily during this pregnancy? Child's birth weight, appearance, and condition? Was baby placed in incubator or isolette? Does child have frequent and/or unusual habits such as bed-wetting, nail-biting, eye-blinking, thumb-sucking, sleep-walking, fears, etc. (list and describe) Does child have regular eating habits? (explain) Does child have regular sleep habits? (explain) Child's usual bedtime? Has the child had any of the following? (please list, tell age, and comments) colic, asthma, measles, mumps, allergies, dizziness, earaches, prolonged high fevers Has the child had any of the following (please list, tell age, and comments) operations, diabetes, fainting, convulsions, unusual headaches, injuries, hospitalizations, other) Has child had chickenpox or the varicella immunization (state which and give month and year) List any that apply to the child (and comment) happy, sad, cruel, jealous, aggressive, generous, shy List any that apply to the child (and comment) restless, makes friends easily (older or younger), irritable, talks back, temper tantrums, cries easily, easily discouraged List 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 communicating With 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?