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Hope Begins Here

Client Demographics

Heart of Florida Youth Ranch

Comprehensive Application for Admission

Section 1: Community-Based Care (CBC) Information

CBC Agency Name:
CBC Region/County:
CBC Agency Address:
CBC Case Manager Name:
CBC Case Manager Phone (Office, Cell, Emergency):
CBC Case Manager Email:
CBC Supervisor Name:
CBC Supervisor Phone:
Funding Source for Placement:
Medicaid
CBC
Other (Specify):

Is this placement court-ordered?
Yes
No
Court Case Number:
Judge’s Name:
Next Court Date:
Is there an active safety plan in place?
Yes
No

Section 2: Dependency Case Manager (DCM/FCM) Information

DCM/FCM Name:
DCM/FCM Agency/Organization:
DCM/FCM Phone:
DCM/FCM Email:
DCM/FCM Supervisor Name:
Supervisor Phone:
Reason for Placement:
Neglect
Abuse
Abandonment
Other (Explain):

Section 3: Client Information

Full Legal Name:
Preferred Name (if different):
Date of Birth:
Gender Identity:
Male
Female
Non-binary
Other
Race/Ethnicity:
Primary Language:
Social Security Number:
Is Birth Certificate Attached?
Yes
No

Section 4: Family History

Biological Mother’s Name:
Biological Mother’s Address:
Biological Mother’s Phone:
Biological Mother’s Occupation:
Mother Custody Status:
Sole Custody
Joint Custody
No Custody
Has the mother’s parental rights been terminated?
Yes
No
Biological Father’s Name:
Biological Father’s Address:
Biological Father’s Phone:
Biological Father’s Occupation:
Father Custody Status:
Sole Custody
Joint Custody
No Custody
Has the father’s parental rights been terminated?
Yes
No

Section 5: Authorization Forms

Release of Information Authorization:
Medical Authorization:
YMCA Participation Authorization:

Section 6: Visitation and Contact List

Approved Visitor 1 Name:
Visitor 1 Relationship to Client:

Section 7: Medical Information

Client's Full Name:
Date of Birth:
Insurance Provider:
Policy Number:
Primary Physician's Name:
Primary Physician's Contact:

Medical Conditions

Please list any known medical conditions: Please list any past surgeries: Allergies (medication, food, etc.):

Medical History Diagnoses

Please check all that apply:

Asthma
Diabetes
Epilepsy
Heart Disease
Hypertension
Allergies
ADHD
Anxiety
Depression
Bipolar Disorder
Autism Spectrum Disorder
PTSD
Other (Please specify below):

Current Medications

Please list any current medications:

Immunization History

Please list all known immunizations:

Emergency Contact Information

Emergency Contact Name:
Relationship to Client:
Emergency Contact Phone Number:
Emergency Contact Address:

Section X: Guardian Ad Litem Information

Guardian Ad Litem Name:
Guardian Ad Litem Phone Number:
Guardian Ad Litem Email:
Additional Notes Regarding Guardian Ad Litem:

Section Y: Mental Health Questionnaire

Has the client been diagnosed with any mental health conditions?
Yes
No
If yes, please list the diagnosed conditions:
Has the client previously participated in therapy or counseling?
Yes
No
If yes, please provide details (e.g., type of therapy, duration):
Is the client currently taking any medications for mental health conditions?
Yes
No
If yes, please list the medications:

Document Uploads

Upload Placement Letter:
Upload Court Order:
Upload Child Placement Assessment:
Upload Child Placement Agreement (CPA):
Upload Birth Certificate:
Upload Social Security Card:
Upload Education Documents:

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