Tulsa Girls' Home Admission

Resident Information

Date *

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First Name *

Middle Name *

Last Name *

Date of Birth *

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Social Security Number *

Admitted by the order of (Name of Social Worker, Probation Officer, Judge) *

Date of Referral *

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Referring County *

Referring Agency: *

Full Name of Case Worker *

Contact Phone Number of Case Worker *

Email of Case Worker *

Description of the circumstance(s) that led to the resident's referral: *

Description of the resident's current and past behavior: *

Description of the resident's social history and school performance/problems: *

Name of current (or most recent) enrolled school: *

Current grade level *

7th Grade

8th Grade

9th Grade

10th Grade

11th Grade

12th Grade

Is the resident on an IEP (Individual Education Plane) *

Yes

No

Unknown

Resident's history of any other placements outside the home, including the reasons for placement(s) and removal/discharge: *

Medical & Emergency Information

Emergency Contact's Full Name: *

Emergency Contact's Phone Number: *

Emergency Contact's Mailing Address: *

Secondary Emergency Contact's Full Name: *

Secondary Emergency Contact's Phone Number: *

Secondary Emergency Contact's Mailing Address: *

Resident's immunization record, medical and dental histories, including current medical problems: *

Please list the resident's current medications, dosage, and medical regiment: *

Resident's Current Psychiatrist Name: *

Resident's Current Psychiatrist Phone Number: *

Resident's Current Physician: *

Resident's Current Physician's Phone Number: *

Resident's Current Therapist's Name: *

Resident's Current Therapist's Phone Number: *

Briefly explain resident's mental health history: *

Family Information

Custodial Parent(s)/Guardian(s):

Mother's Name: *

Mother's Phone Number: *

Father's Name: *

Father's Phone Number: *

Home Address: *

Non-Custodial Parent(s)/Significant Other/Guardian Name & Relationship to the Resident *

Non-Custodial Parent(s)/Significant Other/Guardian Name & Relationship to the Resident

Sibling #1 Name, Age, Brother/Sister - Full/Half/Step

Sibling #2 Name, Age, Brother/Sister - Full/Half/Step

Sibling #3 Name, Age, Brother/Sister - Full/Half/Step

Sibling #4 Name, Age, Brother/Sister - Full/Half/Step

Sibling #5 Name, Age, Brother/Sister - Full/Half/Step

Additional Comments and Observations:

Resident's Money & Valuables Verification/Inventory

Does the resident currently have money or valuables in her belonging: *

Yes

No

Current dollar amount in the resident's possession. (TGH staff will secure this money in a locked area and issue a receipt). *

Please list any documents (i.e. ID, DL, SSN, Medical Card, Passport) and valuables that need to be secured or held until discharge. TGH is not responsible for locating money or valuables that are not specified on this form. *

Signatures Upon Intake

Electronic Name/Signature of Resident *

Date the Resident Signed Intake Form: *

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Electronic Name/Signature of DHS Representative/Caseworker *

Date the Caseworker Signed Intake Form: *

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Electronic Name/Signature of TGH Representative/Director *

Date the TGH Staff/Director Signed Intake Form: *

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