Online Enrollment Form

Name:


Date of Admission:


Admission Checklist
(please select whether or not you have the following information/documentation):

L. O. C. CONFIRMATION DOCUMENTAION/DATE

COURT ORDER, IF APPLICABLE

BIRTH CERTIFICATE

FORM 2085

MEDICAL RELEASE FORM 2085 - A

DESIGNATION/MEDICAL CARE PART B

UPDATED COMMON APPLICATION/FAMILY HISTORY

SERVICE PLAN

SOCIAL SECURITY CARD


SIGNED CONSENT FORMS:

CLOTHING VOUCHER, IF APPLICABLE


CLINICAL SERVICES:

CURRENT PSYCHIATRIC/PSYCHOLOGICAL EVALUATION

WITHDRAWAL, IEP, COMPREHENSIVE INDIV. ASSESSMENT

REPORT CARD, TRANSCRIPT/LAST SCHOOL ATTENDED

CURRENT PHYSICAL, DENTAL AND VISION SCREENING

IMMUNIZATION RECORDS

MEDICAID CARD

Additional Comments: