Auldern Academy
Application for Admission

DEMOGRAPHIC INFORMATION

Date:
Full Name of Student:
Street Address:
DOB:
SS#:
Was the applicant adopted? Yes   No
If yes, at what age?

PARENT/GUARDIAN INFORMATION

Mother/guardian name:
Does this person have custody of the applicant? Yes   No
Address:
Stepfather name:
Contact information:


Father/guardian name:
Does this person have custody of the applicant? Yes   No
Address:
Stepmother name:
Contact information:


REFERRAL SOURCE

How did you find out about Auldern Academy?
Independent Educational Consultant
Another parent
Mental Health Professional
Auldern or Sequel TSI staff
Publication
Internet
Other
Name:
Describe:

EDUCATION HISTORY — list all high schools where the student has been enrolled:

1)

Dates of attendance: -

2)

Dates of attendance: -

3)

Dates of attendance: -

MEDICAL INFORMATION

Please describe the student's general health:
Date of last physical:
Please describe findings:
Current medications:
List any allergies to foods, drugs or other substance:
Does the student have any history of epileptic or convulsive disorder? Yes   No
If yes, please describe:
Does the student have any medical problems or handicaps which might interfere with full participation in school activities? Yes   No
If yes, please describe:
Is a special diet ordered? Yes   No
If yes, please explain:

LEGAL HISTORY

Has the student been ever been involved with the law? Yes   No
If yes, please give details and disposition: shoplifting with group of girls, charges dropped completed PTI:

SUBSTANCE ABUSE INFORMATION

Has the student used substances? Yes   No
If yes, please list types of substances abused:
Describe frequency of use:

PRESENTING PROBLEM

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.

1)

Dates of treatment: -
Name of treating professional:
hospitalization
out-patient
day treatment
under care of psychiatrist
substance abuse
Other:

2)

Dates of treatment: -
Name of treating professional:
hospitalization
out-patient
day treatment
under care of psychiatrist
substance abuse
Other:

3)

Dates of treatment: -
Name of treating professional:
hospitalization
out-patient
day treatment
under care of psychiatrist
substance abuse
Other:
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
  • Custody documentation
  • Signed Consents for Release of Information (copy extra as needed)
Auldern Academy
990 Glovers Grove Church Road
Siler City NC, 27344
Phone: (855) 958-0518