EDUCATION HISTORY — list all high schools where the student has been enrolled:
Please describe the student's general health:
List any allergies to foods, drugs or other substance:
If yes, please give details and disposition: shoplifting with group of girls, charges dropped completed PTI:
SUBSTANCE ABUSE INFORMATION
If yes, please list types of substances abused:
Describe frequency of use:
Please describe the recent events or behaviors that have brought about this application for enrollment at Auldern:
Briefly describe what you hope Auldern Academy can accomplish for the applicant:
TREATMENT HISTORY — list all therapeutic programs, mental health or substance abuse treatment the applicant has undergone. Please use an extra sheet of paper if necessary. List in order of most recent first.
Along with this application, the following should be submitted for review:
All recent psycho-educational testing and diagnostic evaluations within the last three years
Previous treatment reports, including hospital admission/discharge reports
School records from most recent school placement
IEP for applicants with special education needs
Signed Consents for Release of Information (copy extra as needed)
CONSENT FOR RELEASE OF STUDENT INFORMATION
and (specify person(s) or organization with complete address, email address, and/or telephone number):
to release specified information from my record(s) to each other and to communicate in conjunction with the information released throughout my enrollment at Auldern Academy.
This information shall include:
Academic Progress Reports
Medical Treatment Records
The doctrine of informed consent has been explained to me, and I understand the information to be released, the need for the information, and that there are statutes and regulations protecting the confidentiality of authorized information. I hereby acknowledge that this consent is truly voluntary and is valid until such request is fulfilled. I further acknowledge that I may revoke this consent at any time except to the extent that action based on this consent has been taken. This consent shall expire 365 days from the date of my signature below.