ON-CAMPUS LIVING REFERRAL

Client Information

First Name

Middle Name

Last Name

Birth Date

Birthplace

Religious Preference

Current Address

County

Primary Medical Insurance

ID#

Secondary Medical Insurance

ID#

Social Security Number

Sex

Gender Identity

Height

Weight

Hair Color

Eye Color

Race

Allergies (including medications, food, environmental)

Current Medications

Current School

Current Grade

Home School District

Special Ed?

Custody

Parents

Joint

Mother

Father

Agency

Date Custody Granted

Special Circumstances

Placement History (including foster care, hospitalizations, etc., with dates)

Other Professional Contacts (not listed above, including psychiatrists, mental health centers, etc.)

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Financial Responsibility for Treatment

Family Information

Guardian/Parent #1 (person completing the application)

First Name

Middle Name

Last Name

Birth Date

Relationship to Client

Current Street Address

City

State

Zip Code

County

Home Phone

Cell Phone

Work Phone

Occupation

Employed By

Annual Household Income

# of People in Household

Guardian/Parent #2

First Name

Middle Name

Last Name

Birth Date

Relationship to Client

Current Street Address

City

State

Zip Code

County

Home Phone

Cell Phone

Work Phone

Occupation

Employed By

Annual Household Income

# of People in Household

Guardian/Parent #3

First Name

Middle Name

Last Name

Birth Date

Relationship to Client

Current Street Address

City

State

Zip Code

County

Home Phone

Cell Phone

Work Phone

Occupation

Employed By

Annual Household Income

# of People in Household

Sibling Information

Names, Dates of Birth, Current Whereabouts

Required Documents

The following documents must be submitted PRIOR to admission.
- Copy of Birth Certificate
- Copy of Social Security Card
- Copy of Medicaid/Insurance Card
- Copy of Immunization Record

If available, please submit the following documents.
- Discharge Summaries from previous placements
- Psychiatric Evaluations from previous placements
- Psychological Assessments, including IQ testing
- Social History
- Medical History
- School records, grades/credits earned to date, etc.
- Copy of IEP & IEP Evaluation (if applicable)

Questions? Please email residential.admissions@cornerstonesofcare.org.