Preliminary Admissions Form

If you are interested in placing your child at Hill Country Youth Ranch or its sister campus Big Springs Ranch for Children, please complete the following form to enable us to make an initial assessment of the child's needs.

Title:
First Name:
Middle Name:
Last Name:
Suffix:

Mailing Address
Street Address 1:
Street Address 2:
City:
State:
ZIP Code:

Home Phone:
Cell Phone:
Email Address:

(Please be ready to provide written permission for any or all of these professionals to share information with our treatment team regarding child and family.)
Child's Age:
Has child ever had a psychological or psychiatric evaluation?:
Has the child been receiving psychological services?:
Briefly describe specific incidents necessitating placement:
Other Behaviors:
Explain the checked boxes:

School Information
Grade Average:
Special Ed Class:
Has the child been diagnosed as emotionally disturbed or learning disabled?:
Describe the child's current educational program:
Describe the child's current educational program:
Briefly describe concerns about school (behavior, performance, aptitude, truancy, etc.):
Special needs of child (medical, emotional, physical, learning, etc.):
Additional information you would like us to consider?:
 

Please remember that a careful consideration of your child's needs requires a comprehensive dialogue and the sharing of sensitive information. We assure confidentiality, but we require your full cooperation so that we do not subject a child to unnecessary failure owing to an inappropriate placement.