Auldern Academy
Application for Admission

DEMOGRAPHIC INFORMATION

Date:
Full Name of Student:
DOB:
Grade:
Nickname/Preferred Name:
SS#:
Street Address:
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)

CONSENT FOR RELEASE OF STUDENT INFORMATION

Student Name:
DOB:
Grade:
SS#:
I hereby authorize:
Auldern Academy
990 Glovers Grove Church Road
Siler City, NC 27344
(919) 837-1100
eileen.antalek@sequelyouthservices.com
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:
School Transcripts
Academic Progress Reports
Clinical Information
Immunization Records
Medical Treatment Records
Sobriety Information
Other (describe)
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.
Student's signature (over 18):
Date:
Parent/Legal Guardian's signature:
Date:
Auldern Academy
990 Glovers Grove Church Road
Siler City, NC 27344
Phone: (919) 837-2336