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 Mr.Mrs.MissMs.Dr.Prof.Rev. Title First Middle Last Suffix Mailing Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneEmail 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 AgeHas child ever had a psychological or psychiatric evaluation?YesNoWhen? Has the child been receiving psychological services?YesNoHow Long0 to 6mos6mos to 1yr1yr to 2yrs2 to 5yrsOver 5yrsTypes of Services Therapist Psychologist Psychiatrist Briefly describe specific incidents necessitating placementOther 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 boxesSchool InformationGrade AverageSpecial Ed ClassesYesNoHas the child been diagnosed as emotionally disturbed or learning disabled?YesNoDescribe 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.