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Application for Services
Form no. 06401 FS-RS Rev. 3/2017
APPLICATION
FOR
______________________________
Name
Bill Anoatubby
Governor
the
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 2 of 24 Form no. 06401 FS-RS Rev. 3/2017
Dear Parent or Legal Guardian:
Enclosed is an application for admission to Aalhakoffichi’. Please complete and sign each page and
return it to us as soon as possible. Each of the items listed must be received to complete this
application. Adolescents cannot be considered for admission without these items:
Copy of your adolescent’s:
1. Certificate of Degree of Indian Blood or tribal letter
2. Up-to-date immunization record
3. Birth certificate
4. Social Security card
5. School transcript or most current grades
6. Private insurance, Medicaid or SoonerCare insurance card
7. Current contact list
PLEASE NOTIFY US IMMEDIATELY OF ALL ADDRESS AND PHONE NUMBER CHANGES
Sincerely,
Authorized representative signature
Enclosure: Application
All forms must be completely filled out and notarized before your application can be
considered for admission.
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 3 of 24 Form no. 06401 FS-RS Rev. 3/2017
APPLICATION FOR ADMISSION
Returning (if returning resident) New
Name of adolescent: Grade:
Gender: Male Female Birth date: Social Security no.:
Affiliated Indian tribe(s): Degree:
Church preference: Can student attend another church? Yes No
Name and address of parent or legal guardian:
Home phone: Work phone:
Directions to your home:
Name and phone number of neighbor, friend or relative:
Has adolescent ever lived in a transitional living facility before? Yes No
If so, where?
Does the adolescent want to come? Yes No If no, please explain:
Reason for referral:
(Please put any additional information on back of page.)
Names of brothers and sisters:
1. Male Female Age:
2. Male Female Age:
3. Male Female Age:
4. Male Female Age:
5. Male Female Age:
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Bill Anoatubby
Governor
Page 4 of 24 Form no. 06401 FS-RS Rev. 3/2017
Please initial one or more of the items below if you wish to give your adolescent permission to leave
the Aalhakoffichi’ campus without the sponsorship of the Aalhakoffichi’ facility.
1. ____ Resident is to leave only with written permission each time from parent/legal guardian.
2. ____ Resident is to leave campus only with parent or legal guardian.
3. ____ Resident is to leave campus with authorized persons listed below: MUST be over 21 years
of age.
4. ____ To add other names to the check-out list, a parent/legal guardian must submit a signed
permission statement through fax, letter or in person to the director 48 hours prior to
resident check-out.
(1) (3)
(2) (4)
I, _____________________________, am legally responsible for
and understand that Aalhakoffichi’ is released of responsibility whenever the adolescent is checked out
by authorized persons.
Aalhakoffichi’ may request additional information before the adolescent is enrolled.
Signature of parent/legal guardian Date
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 5 of 24 Form no. 06401 FS-RS Rev. 3/2017
FAMILY AND INSURANCE INFORMATION
Person filling out form: Parent Legal guardian
Father: ______________________________
Age: ____ Living Deceased
Address: _____________________________
_____________________________________
City State ZIP
Phone: Home: _______________________
Work: _______________________
Emergency: ___________________
Tribal affiliation: _______________________
Dominant language spoken in the home: ____
_____________________________________
Home agency: ________________________
Do you have Medicaid (SoonerCare)?
Yes No If yes, what is the Medicaid
number/person code? _________________
Do you have private/group health insurance?
Yes No If yes, please provide the
insurance company’s name and address:
___________________________________
___________________________________
Name of insured: _____________________
Relationship to adolescent: (please check one)
Parent Legal guardian
What is the policy ID or Social Security no.?
___________________________________
Group name/group number: _______________
Father’s known allergies: _________________
______________________________________
Mother: ______________________________
Maiden name: _________________________
Age: ____ Living Deceased
Address: _____________________________
_____________________________________
City State ZIP
Phone: Home: _______________________
Work: _______________________
Emergency: ___________________
Tribal affiliation: _______________________
Dominant language spoken in the home: ____
_____________________________________
Home agency: ________________________
Do you have Medicaid (SoonerCare)?
Yes No If yes, what is the Medicaid
number/person code? _________________
Do you have private/group health insurance?
Yes No If yes, please provide the
insurance company’s name and address:
___________________________________
___________________________________
Name of insured: _____________________
Relationship to adolescent: (please check one)
Parent Legal guardian
What is the policy ID or Social Security no.?
___________________________________
Group name/group number: _______________
Mother’s known allergies: _________________
______________________________________
Bill Anoatubby
Governor
Governor
Page 6 of 24 Form no. 06401 FS-RS Rev. 3/2017
ASSIGNMENT OF BENEFITS
Adolescent’s name:
Street: City: State: ZIP:
Gender: Male Female DOB: SSN: Age:
Email address:
Emergency contact: Relationship:
Address: City: State: ZIP:
Phone:
Primary insurance:
□ Medicaid Medicaid #: Renewal date:
Please give receptionist your card to copy.
□ Private insurance Policy holder’s name: Group no.:
Insurance ID no.: Phone:
Address, if different than client:
AUTHORIZATION TO RELEASE INFORMATION/ASSIGNMENT OF BENEFITS
I authorize the release of any medical information necessary to process this claim. I permit a copy of this authorization to
be used in the place of the original.
DATE: SIGNATURE:
I hereby authorize the Family Resource System - Ada to apply benefits on my behalf for covered services. I request that
payment from my insurance company be made directly to the Family Resource System - Ada (or to the party that accepts
the assignment).
I certify that the information I have reported regarding my insurance coverage is correct. I permit a copy of this
authorization to be used in place of the original. Either my insurance company or I may revoke this authorization at any
time in writing.
DATE: PARENT/LEGAL GUARDIAN SIGNATURE:
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 7 of 24 Form no. 06401 FS-RS Rev. 3/2017
Aalhakoffichi` applicant:
Name: ______________________________________________________________________________________________________
First Middle Last
_________________ ________ ________________________________________________ ____________________________
Birth date Gender Parent/legal guardian name Home phone
PLEASE ANSWER THE FOLLOWING QUESTIONS CAREFULLY AND ACCURATELY. ASK ABOUT ANY QUESTION YOU DO NOT
UNDERSTAND. IF MORE SPACE IS NEEDED, SHOW NUMBER AND EXPLAIN ON BACK OF SHEET.
1. Is the adolescent being treated by a doctor now? YES NO
If yes, explain: _________________________________________________________________________________
2. Has the adolescent ever had any serious illness, been hospitalized or had any medical treatments, tests or surgeries?
YES NO
If yes, explain: _________________________________________________________________________________
3. Is the adolescent taking any medications (including over-the-counter, herbal, birth control, etc.) now? YES NO
In the past year? YES NO
If yes, explain: _________________________________________________________________________________
4. Has the adolescent ever had any of the following conditions? Explain below and give date or age.
YES
NO
Dt/Age
YES
NO
Dt/Age
YES
NO
Dt/Age
1. Respiratory disease
8. Anemia
15. Arthritis
2. Heart problems or
disease
9. Asthma
16. Epilepsy
3. Heart murmur
10. Allergies/sinus
17. STDs
4. High blood pressure
11. Tuberculosis
18. Kidney disorders
5. Stroke
12. Hepatitis
19. Circulation problems
6. Rheumatic fever
13. Jaundice
20. Skin disorders
7. Diabetes
14. Liver disease
21. Stomach disorders
5. Is the adolescent allergic to any drug or medicine of any kind – such as penicillin, codeine, novocain, lidocaine, etc.?
YES NO
If yes, explain: ________________________________________________________________________________
6. Is the adolescent allergic to anything (including food, insect stings, pollen, etc.) resulting in swelling, hives, asthma, etc.?
YES NO
If yes, explain: ________________________________________________________________________________
7. Has the adolescent ever had excessive bleeding that required treatment? YES NO
If yes, explain: ________________________________________________________________________________
8. Has the adolescent ever had a blood transfusion or blood products? YES NO
If yes, explain: ________________________________________________________________________________
9. Does the adolescent have any wounds or injuries that heal slowly or have other complications? YES NO
If yes, explain: ________________________________________________________________________________
10. Has the adolescent had any joint replacements? □ YES □ NO
Bill Anoatubby
Governor
For office use only:
Chickasaw Nation Medical
Record no:
_______________________
Other: __________________
__________________
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 8 of 24 Form no. 06401 FS-RS Rev. 3/2017
11. Has the adolescent had any artificial limbs or lens implants? YES NO
12. Has the adolescent ever fainted or been knocked unconscious? YES NO
If yes, explain: ________________________________________________________________________________
13. Is the adolescent on any special diet at this time? YES NO
If yes, explain: ________________________________________________________________________________
14. Has the adolescent had x-ray treatment (besides for fractures and routine chest x-rays)? YES NO
If yes, explain: ________________________________________________________________________________
15. Does the adolescent have any disease, condition or problem that you think the doctor or dentist should know about?
YES NO
If yes, explain: ________________________________________________________________________________
16. Is the adolescent pregnant? YES NO N/A
17. Has the adolescent had any trouble associated with dental treatment? YES NO
If yes, explain: ________________________________________________________________________________
18. Is the adolescent current on immunizations? YES NO
19. Is there any suspicion that the adolescent is using drugs or alcohol? YES NO
Parent/legal guardian signature: _______________________________________________________ Date: ____________________
Page 9 of 24 Form no. 06401 FS-RS Rev. 3/2017
Photo
Aalhakoffichi` will provide
Name:
Height: Weight: Hair Color: Eye Color:
Tattoos: Hair Length: Scars:
Remarks/details:
I, being the parent/legal guardian of
hereby give Aalhakoffichi’ staff authorization/responsibility to initiate proceedings for detention orders, missing
persons reports, runaway juvenile reports and/or any documents/procedures needed in the event my
adolescent leaves Aalhakoffichi’ or the public school he is attending or any Aalhakoffichi’ activities or school
activities without expressed permission from Aalhakoffichi’ staff. The permission is given so that my adolescent
may be located and returned to a safe environment as soon as possible.
Signature of parent or legal guardian Date Signature of witness Date
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 10 of 24 Form no. 06401 FS-RS Rev. 3/2017
AUTHORIZATION FOR TREATMENT AND DISCLOSURE OF CLINICAL INFORMATION
I am legally responsible for _____________________________ and hereby give consent for any medical,
dental, counseling, substance abuse screening and drug/alcohol treatment that become necessary while the
adolescent resides at Aalhakoffichi’. I also approve such inoculations and treatments in the field of preventive
medicine as may be deemed necessary by medical personnel.
I further understand that I will be notified by ATLC when emergency situations arise in any medical, dental,
counseling, substance abuse screening and drug/alcohol treatment situations involving my adolescent while at
ATLC.
I authorize this release knowing and understanding the records may contain information relating to a
reportable communicable disease, which is confidential according to applicable law.
I further consent for the disclosure and exchange of pertinent information essential for medical treatment,
drug/alcohol treatment and substance abuse screening or counseling services. This information may be
exchanged between the _________________________ (name of medical provider) and the Aalhakoffichi`
beginning _________________________ and ending _____________________.
Consent is given for a drug screening to be done upon acceptance of application.
Signature of parent/legal guardian Address
Relationship City State ZIP
Date Phone number
State of
County of:
Signed before me on 20
By
Identification
My commission expires
Notary Public
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 11 of 24 Form no. 06401 FS-RS Rev. 3/2017
PLEASE PRINT DATE OF EXAM:
MEDICAL HISTORY
Date of last doctor visit:
Name of medical facility:
Allergies: Yes No If yes, specify:
Medical problems: Yes No If yes, specify:
Current medications: Yes No If yes, specify:
PREPARTICIPATION PHYSICAL EVALUATION
Name: Birth date:
Height: Weight: Body fat (optional): % Pulse:
BP: _____/_____ _____/_____ _____/_____
Initial BP Post exercise 5 min. post ex.
Vision: R 20/_____ L 20/_____ Corrected: Yes No Pupils: Equal _____ Unequal _____
_________________________________________________________________________________________________
MEDICAL
NORMAL
ABNORMAL FINDINGS:
Appearance
Eyes/ears/throat
Lymph nodes
Heart
Pulses
Lungs
Abdomen
Genitalia (male only)
Skin
MUSCULOSKELETAL
Neck
Back
Shoulder/arm
Elbow/forearm
Wrist/hand
Hip/thigh
Knee
Leg/ankle
Foot
CLEARANCE
Cleared
Cleared after completing evaluation/rehabilitation for:
Not cleared for: Reason:
Recommendations:
Name and title of examiner (print/type): Date:
Address: Phone:
Signature of examiner:
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 12 of 24 Form no. 06401 FS-RS Rev. 3/2017
RELEASE OF CONFIDENTIAL INFORMATION
I, , hereby give my consent to
(Parent/legal guardian) (Doctor, hospital, clinic, agency or school)
its directors, designee or records department, to release information contained in
(Adolescent’s name)
DOB: SSN: Record number:
records to the individual or organization listed below:
1. Name or title of person(s) or organization to whom disclosure is to be made:
ATTN: Aalhakoffichi’ Method(s) of Release:
111 Arrowhead Drive Verbal telephone Written
Pauls Valley, Oklahoma 73075 Electronic mail Fax
2. Specific type of information to be disclosed:
Medical Psychological Vocational
Other: ________________________________________________________________________
3. The purpose and need for such disclosure:
Establish eligibility for services Case staffing
Determine need for and/or type of treatment Other: ___________________________
4. The confidential information I authorize for release may include information about communicable or
venereal disease, which may include, but is not limited to, diseases such as hepatitis, syphilis,
gonorrhea and the human immunodeficiency virus, also known as acquired immune deficiency
syndrome (AIDS).
5. I understand this release may be revoked at any time and shall be valid no longer than is reasonably
necessary to accomplish the purpose for which it is given.
6. This release expires upon the resident’s exit from Aalhakoffichi’, unless otherwise indicated.
__________________________________________ _________________ ________________________
Parent/legal guardian signature Date Relationship
__________________________________________ ________________ ________________________
Witnessed by Title Date
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 13 of 24 Form no. 06401 FS-RS Rev. 3/2017
PRIVACY ACT UNDERSTANDING AND LEGAL SIGNATURE FORM
I have read the Privacy Act Notice (Public Law 93-579) and have been informed that my adolescent’s
records are located in the health and medical records system at:
The Chickasaw Nation Medical Center
I understand that the information given by me or collected is necessary for the Chickasaw Nation
Medical Center to provide services for my adolescent’s health and well-being. Furthermore, I have
been informed that my adolescent’s records or any portion of the records shall not be disclosed to
another agency or person unless specified as routine use without my signed consent.
I give permission for Aalhakoffichi’ staff to accompany my adolescent to the health facility and to be in
the examination room during appointments (with the exception of mental health appointments).
___________________________________________
Adolescent name
___________________________________________ ________________________________
Signature of parent/legal guardian, if adolescent it a minor Date
___________________________________________ ________________________________
Signature of witness Date
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 14 of 24 Form no. 06401 FS-RS Rev. 3/2017
CONSENT FOR URINE DRUG SCREEN
Adolescent name: SSN: Date:
Aalhakoffichi` has a zero tolerance substance abuse policy.
In keeping with this policy it may be necessary to do random drug testing as needed while my
adolescent is on the Aalhakoffichi’ campus. I understand that this screening will be a urine drug
screening. My signature below indicates that I give my consent for my adolescent to receive urine
drug screens at Aalhakoffichi’. I further understand that staff of the same gender may observe
collection of urine. Results from these screenings will be confidential and known only to necessary
staff and that I will receive results if requested.
This consent is in effect from to .
Date Date
Signature of parent/legal guardian Date
Signature of witness Date
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 15 of 24 Form no. 06401 FS-RS Rev. 3/2017
EDUCATION INFORMATION
Previous school attended:
Address:
Date and grades completed:
Please provide most current copy of your report card.
Reason for leaving if applicable:
Has your adolescent: (check appropriate boxes)
Been retained in same grade? Yes No Been tested for special education,
Attention Deficit Disorder and/or Learning
Disabilities Disorder?
Yes No Please explain:
Received speech therapy? Yes No Been in special education classes or have
classroom modifications? Yes No
Consent for Release of Education Records
I authorize ______________________School District and all education departments thereof to release all
portions of my adolescent’s educational record, which may be confidential or otherwise, including special
education records, to:
Aalhakoffichi’ (A place for healing)
111 Arrowhead Drive
Pauls Valley, Oklahoma 73075
(405) 331-2300
Fax: (405) 331-2302
Adolescent name: Birth date:
Signature of parent/legal guardian: Date:
Attention: According to the Family Educational Rights and Privacy Act of 1974 (Public Law 93-380) the
parents, legal guardians or 18-year-old students have the right to make a written request to view any records
released.
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 16 of 24 Form no. 06401 FS-RS Rev. 3/2017
AALHAKOFFICHI’ ADOLESCENT TRANSITIONAL LIVING CENTER
I, ______________________, understand and give my permission for my adolescent, _____________________,
to participate in the adolescent transitional living center (ATLC) activities. I further understand some of these activities will
be outside ATLC property and will require transporting my adolescent to events or activities. I give my permission for the
Aalhakoffichi’ staff to accompany my adolescent to program activities and other events when necessary. I understand I
will be informed when my adolescent will be going to any such event.
WAIVER OF RESPONSIBILITY OF PERSONAL INJURY AND/OR LIABILITY
By the presence of this document, be it known that I/we, and
Parent/legal guardian
, do hereby waive the right of holding responsible the Chickasaw Nation, any
Participant
division within the Chickasaw Nation or any person or individual connected with instruction and/or participation in
Aalhakoffichi’ events and activities. I/We understand and acknowledge that there are hazards or dangers associated with
participating in this program, and I/we agree to participate with knowledge of said dangers and hazards. Injury occurring to
my/our adolescent or me/us either by direct or indirect means will be my/our sole responsibility. No individual or entity,
including but not limited to, the Chickasaw Nation and divisions within the Chickasaw Nation, the ATLC staff or other
participants, will be held liable for any damages or injuries. I/We have both read this entire form and it has been explained
to us fully. Therefore, without coercion or duress, I/we affix our signatures to this document with full understanding of the
statements contained herein, and agree to be bound by such agreement from this moment on for the duration of my/our
adolescent’s participation with the Aalhakoffichi’ Program.
_________________________________ ___________________________________ _______________
Name of participant (print) Signature of participant Date
_________________________________ ___________________________________ _______________
Name of parent/legal guardian Signature of parent/legal guardian Date
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 17 of 24 Form no. 06401 FS-RS Rev. 3/2017
AALHAKOFFICHI’ ADOLESCENT TRANSITIONAL LIVING CENTER HANDBOOK
The Aalhakoffichi’ Handbook is presented to each adolescent and parent/guardian during orientation
or when the resident is admitted to Aalhakoffichi’. The staff has read or explained Aalhakoffichi`
expectations and rules to the residents and parents/guardians.
I, (resident), have been provided with the
Aalhakoffichi’ Handbook and understand that I must follow the guidelines outlined in this handbook.
Nothing contained in this application, Aalhakoffichi’ Handbook or any other Aalhakoffichi’ documents
shall be construed to waive the sovereign rights of the Chickasaw Nation, its officers, employees or
agents.
Signature: Date:
I, , parent/legal guardian of , have
been provided with the Aalhakoffichi’ Handbook and understand and will help my adolescent abide by
the rules outlined within this handbook.
Signature of parent/guardian: Date:
Signature of program manager: Date:
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 18 of 24 Form no. 06401 FS-RS Rev. 3/2017
Adolescent Intake Form
I. Demographics
Last name: First: M.I.:
Address: City: State: ZIP:
Birthplace: Birth date: Age: Gender:
Ethnicity: Tribal affiliation:
Telephone (home): (office): (cell):
Name of person completing form:
Are you the parent of the adolescent? Yes No
If no, are you the legal guardian? Yes No
In case of an emergency, contact: Name: Telephone:
Address:
II.
Present life situation
List all household members
Name
Age
Relationship
History of drug or alcohol abuse?
Do you live in: house apartment duplex other:
Do you have: running water electricity gas propane other:
How are your basic needs met? (sources of income):
Are you involved in social activities? Yes No
If yes, describe:
Have there been any significant changes to these activities in the past six months? Yes No
If yes, describe:
Is the adolescent’s parent/guardian and/or another adult committed to the adolescent, willing to
participate in therapeutic services? Yes No
If yes, describe:
Bill Anoatubby
Governor
The
Chickasaw Nation
Aalhakoffichi` - A Place for Healing
Adolescent Transitional Living Center
101 Arrowhead Drive / Pauls Valley, Oklahoma 73075 / (405) 331-2300 / Fax (405) 331-2302
Page 19 of 24 Form no. 06401 FS-RS Rev. 3/2017
Parents’ information:
Father’s name: Occupation:
Address:
Education level: Birth date:
Mother’s name: Occupation:
Address:
Education level: Birth date:
Stepparents’ information (if applicable):
Name: Birth date:
Occupation: Education level:
Describe the relationship with adolescent:
Schedule of visitation with non-custodial parent:
What was the age of the adolescent when stepparent entered the family?
III. Medical/emotional history
Please list all inpatient and outpatient treatment for major medical/mental health issues.
Reason
Where
When
How long?
Doctor/counselor
Please list adolescent’s primary care physician:
Is your adolescent on any medications? Yes No
If yes, please list (include over the counter medication):
Are there any significant allergies (including medication)? Yes No
If yes, please list:
Has there been any testing for possible special education and/or school placement? Yes No
If so, please list:
IV. Development
Pregnancy and labor
Was there any complication related to the pregnancy of this adolescent? Yes No
If yes, please list:
Page 20 of 24 Form no. 06401 FS-RS Rev. 3/2017
Please list all medications taken during pregnancy:
During the pregnancy:
How many cigarettes were smoked a day?
How often was alcohol used? Quantity:
How often were street drugs used? Quantity:
Did the adolescent require oxygen at birth?
Was the adolescent cuddly as a baby?
Was the adolescent irritable as a baby?
Developmental Milestones
At what age did the adolescent:
Sit independently: Crawl: Walk independently:
Does the adolescent have difficulty with age appropriate activities? (e.g., riding a bike, catching a ball,
dressing, etc.)
Does/did the adolescent coo, babble and generally respond to attempted communication?
V. Education
What is the adolescent’s current grade level?
Please list any problems the adolescent has experienced at school:
What adjustments have been made to address these problems?
Please indicate if the adolescent has a problem with:
…. alertness to the world around him/her?
…. attention span?
…. ability to problem solve?
…. ability to do math in his/her head?
…. appears to be on grade level with other adolescents his/her age?
Are there any speech, language, hearing, visual or other learning disabilities? If so, please describe:
Does the adolescent have an immunization record that has been verified by school?
Page 21 of 24 Form no. 06401 FS-RS Rev. 3/2017
VI. Family history/relations
Please list if the biological parents’ families:
…. had a history of depression or anxiety?
…. had a history of emotional abuse?
…. attempted or committed suicide?
…. used street drugs?
…. had a history of heavy drinking?
…. had problems with the law?
…. had other serious problems?
Describe the adolescent’s parents’ relationship to each other?
Describe the adolescent’s relationship with his/her brothers/sisters:
□ Good
□ Will not relate to them
□ Fair
□ Poor
□ Loving and affectionate
□ Will not share
□ Hits or aggravates
□ Other:
Describe the adolescent’s relationship with his/her peers:
□ Good
□ Will not relate to them
□ Fair
□ Poor
□ Loving and affectionate
□ Will not share
□ Hits or aggravates
□ Other:
______________________________
Does the adolescent have a history of violent behaviors? Yes No If yes, please describe
and include dates:
What responsibilities does the adolescent have at home?
What kinds of discipline are used in the adolescent’s family? (Please check all that apply)
□ Try to talk or reason with the adolescent
□ Spank
□ Deny privileges
□ Nothing works
□ Firm language
□ Stand in corner
□ Other: ___________________________
Which of the above discipline methods seem to work the best?
Have there been any family disruptions, (e.g. death of family member, friend or pet, divorce, violence in the home,
alcohol/drug use in the home, birth of sibling, remarriage, etc.) which might have affected the adolescent?
Page 22 of 24 Form no. 06401 FS-RS Rev. 3/2017
VII. Abuse and trauma history
Has your adolescent ever been a victim of abuse or neglect? Yes No
If yes, please describe:
How has this affected your adolescent?
Has your adolescent ever been sexually molested? Yes No
If yes, when?
How has this affected your adolescent?
Has the adolescent ever been convicted of a crime? Yes No
If yes, please describe:
Has the adolescent ever purposely harmed himself/herself? Yes No If yes, describe what
was occurring at the time, including when it took place:
Has the adolescent ever attempted suicide? Yes No
If yes, please provide date(s)?
Is your adolescent sexually active? Yes No
Has your adolescent had struggles with:
Sexual identity Sexual conflict/guilt Sexual performance
VIII. Addiction history
Has your adolescent been involved in risk taking behaviors (e.g. gangs, stealing, risky driving, DUI/DWI, etc.)?
Yes No If yes, please describe:
How have these behaviors affected his/her personal life (e.g. home, school, work):
Has the adolescent been exposed to addictive behaviors (e.g. tobacco, alcohol, drugs, porn)? Yes No
If yes, please describe:
Page 23 of 24 Form no. 06401 FS-RS Rev. 3/2017
Has the adolescent ever used drugs/alcohol? If yes, please answer the following:
Daily
2-3 x
week
Once
week
2-3 x
month
Once a
month
4-6 x
year
Once a
year
Age at
1
st
use
Date of
last use
Alcohol
Marijuana
Cocaine
Heroin
Methamphetamine
Prescription drugs
Other (name):
Other (name):
Smokeless tobacco:
Smoking tobacco:
Presenting problem
Behavior problems
Age
Mild
Moderate
Severe
1. Excessive crying
______
2. Excessive nail biting
______
3. Excessive vomiting
______
4. Thumb sucking
______
5. Frequent chewing on substances
______
6. Stuttering
______
7. Bed wetting after age 3
______
8. Soiling after age 3
______
9. Chronic constipation
______
10. Chronic diarrhea
______
11. Temper tantrums
______
12. Masturbation
______
13. Extreme shyness
______
14. Extreme goodness
______
15. Fighting and quarrelling
______
16. Lying
______
17. Stealing
______
18. Frequent nightmares
______
19. Sleep walking
______
20. Tics (muscle spasms or jerks)
______
21. Fears
______
22. Fire setting
______
23. Anxious states
______
24. Sexual problems
______
25. Problems with authorities
______
26. Withdrawal from friends
______
27. Running away
______
28. Eating disorder
______
Page 24 of 24 Form no. 06401 FS-RS Rev. 3/2017
Does the adolescent have any other specific fears, emotional reactions, behavioral problems, etc.,
that are a concern?
Please list any other specific question or concerns you would like the evaluation to address.
Is there any additional information that may be helpful to the evaluation of the adolescent?
Would you like information on advance directives? Yes No
Date:
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ATLC App.aspx ATLC Application (The Chickasaw Nation)

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Completed 31 January 2021

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