ADMISSION ASSESSMENT


I. Vital Information
I. Vital Information:

       Name:
       DOB:
       Age:
       Sex:             Race:
       SS#:
       Medicaid#:

       Parents:
       Rights:

       Date of admission:
       LOC:

       Date of Report:


II. Reasons, Expectations, Goals for Placement
	Child:
	Managing Conservator:
	
IIIa. Circumstances Leading to Placement

IIIb. Current Status

IIIc. Diagnoses:
      Medications:

IV. Past History/Life Story








V. Review of Domains
	a. Physical:
		Height:      Weight:
        Physical Stage of Adolescence:
             Pre    Early    Early/Middle    Middle   Late
		Assessment:
		Strengths:
		Special Needs: (Next Physical Exam...; Next Dental Exam: ...)
	b. Familial:
		...
	c. Educational:
	d. Social/Behavioral
	e. Psychological/Emotional:
	f. Self-harm considerations:
	g. Informational:
		Assessment:
		Needs and Strategies:
	
VI Overview of Special Issues:
	Assessment:
	Intermediate Goals:
	Goals For Treatment:
	Discharge Plan:
	Prognosis:
	Estimated Length of Stay: