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Hill Country Youth Ranch

Restoring and Redeeming the Lives of Abused and Abandoned Children

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Admission Information 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.

Your Name
Title First Middle Last Suffix
Mailing Address
Street Address Address Line 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?
- Yes
- No
When?
MM slash DD slash YYYY
Has the child been receiving psychological services?
- Yes
- No
How Long
Types of Services
- Therapist
- Psychologist
- Psychiatrist
Briefly describe specific incidents necessitating placement
Other Behaviors
- Substance Abuse
- Runaways
- Suicide Threats
- Verbal Aggression
- Physical Aggression
- Gang Involvement
- Suicide Attempt
- Fire Starting
- Involved in Juvenile Justice System
- NONE
Explain the checked boxes
School Information
Grade Average
Special Ed Classes
- Yes
- No
Has the child been diagnosed as emotionally disturbed or learning disabled?
- Yes
- No
Describe the child's current educational program
- Mainstream
- Self-Contained (ED or LD )
- Homebound
- Mainstream, Special Ed
- Behavior-Based Alternative
- No School 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.

Hill Country Youth Ranch

3522 Junction Highway
Ingram, TX 78025
Phone: (830) 367-2131
Fax: (830) 367-6108
communications@youth-ranch.org

Big Springs Ranch for Children

10664 US Highway 83 North
Leakey, TX 78873
Phone: (830) 232-7110
Fax: (830) 232-4256
bsinfo@youth-ranch.org

Enhanced Horizons

149 Camp Scenic Loop
Ingram, TX 78025
Phone: (830) 367-4330
Fax: (830) 367-2814
contact@enhancedhorizons.org

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