Admissions Inquiries Please fill out the following form and our admissions coordinator will contact you with next steps Name * First Name Last Name Age * Date of Birth * Marital Status * Single Married Divorce Phone * (###) ### #### Email * Parent/Guardian Info Parent/Guardian Name * First Name Last Name Phone * (###) ### #### Email * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Referral Source How did you first hear about ScenicView Academy? Please include name(s) of student(s), staff, professional(s), and/or program(s). * * Financial Information Is your Parent/Guardian willing to support you throughout the program? * Does the potential student have financial obligations that would impact their ability to participate full time in the program? If yes, please explain. * Mental Health Information Please answer the following questions about your potential student Does the potential student have an IQ of 85 or above? * Yes No Not Sure What official diagnosis(es) have you received from a doctor, psychiatrist, and/or therapist? Write "None" if not applicable. * Please list testing administered and documentation (i.e. academic, intellectual, psychological, IEP/504, treatment plans, discharge summaries, etc.). Testing and treatment notes will be requested by admissions. * Do you currently have any serious mental health issues, including suicidality or self-harm? If yes, please explain. * Have you been diagnosed with a Traumatic Brain Injury? If yes, please explain. * Do you require continuous supervision to be safe or socially appropriate? If yes, please explain. * Behavioral Information Please answer the following questions about your potential student Have you been convicted of a crime? If yes, please explain. * Do you have any extreme behavioral problems or addictions? If yes, please give details. * Are you motivated to live independently? Please explain. * Do you have the potential to live independently? Please explain. * Do you need support in developing residential, vocational, academic, and social skills? Please explain. * Are you willing to receive feedback in all of the areas listed above? * Are you willing and capable of managing daily tasks and self-care? Please explain. Please list any additional details you feel would be helpful for us to know about the potential student. (schooling, living situation, previous services, etc.) * Thank you!
