Client Information


Family Information

Guardian/Parent #1 (person completing the application)

Guardian/Parent #2

Guardian/Parent #3

Sibling Information

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.