Legacy House Admissions Application
Please click here to download the application or complete it below.

The following checklist is to be used as a guide when sending referral information to Legacy House.  Each packet is reviewed by our Program Director for appropriateness for our program.  It is essential that we receive documentation that is current and presents an overall picture of the potential resident.

We appreciate your support, and look forward to working with you.  Should you have any questions., please do not hesitate to call Antoinette Coffey at (757) 737-3050 or Taquisa Simmons at (757) 404-1900.

The following information should be submitted for initial consideration of admission:

  1. Application Form
  2. Medical History
    1. Copy of physical examination including :
      documentation of freedom from communicable disease, including TB
      documentation   of any allergies, chronic conditions and handicaps if  any
    2. Information regarding previous illness, infectious disease, or serious injury requiring
      hospitalization
    3. Copy of complete psychological and or psychiatric evaluations, including I.Q. testing
      scores.
    4. Type and dosage of any medications currently being taken ( accuracy is extremely
      important)
  3. Education
    1. Current IEP, grade placement, disciplinary file, actions, if any.
    2. Copy of Educational Evaluation and testing scores.
    3. Copy of student’s eligibility for Special Education Placement Services
  4. Social and Developmental Summary
    1. Social History describing family structure and relationships, including names and ages of sex and siblings. 
    2. Previous placement history, (staffing reports discharge summary)
    3. Custody status-legal and or physical.
    4. Current behavioral functioning; strengths, talents, problems.
    5. Social security number of applicant
    6. Copy of birth certificate of applicant.

 

At the time of admission, the following documents must accompany the new resident

  1. Insurance
    1. Copy of private insurance card, front and back.
    2. Signed insurance forms for medical and dental purposes
  2. Court Legal Documentation
    1. Copy of probation Rules
    2. Court order

A  Placement Agreement provided by Legacy House must be signed on the date of placement.

I hereby apply for admission of this resident to Legacy House.

Child's Name Last   First   Child Middle Name

Race Nationality: Date of Birth: (xx-xx-xxx)

Place of Birth:

By (Person and Agency submitting Application)
Address: City
State      Zip
Email
Telephone Number: (incl. area code) Emergency Number:

I do hereby certify that I have the right to complete this application on behalf of this client and that the information furnished is true and complete to the best of my knowledge. I further testify that the legal guardianship of this client is held by:

Applicant Name Date

Legal Guardian if not same as above - Name
Address City Sate Zip
Home Telephone Work Telephone
Client Information
Present Age - Years    Months SSN (111-11-1111)

Where was client residing prior to placement?

Name: Street Address

City State Zip
Client Religious Preference
Does client have Medicaid coverage or other Life, Health, or Hospital coverage?
Company Name Policy Number
Past serious illnesses or infectious diseases
Allergies
Medical Problems
Current medications
Date of last physical examination: Condition
Psychiatric Evaluation, if applicable (please submit)
Date: Condition
Neurological Evaluation, if applicable (please submit)
Date: Condition
DSM IV Diagnosis:
Axis I: Axis II: Axis III
Axis IV: Axis V:
Client's Physician:
Address: City State Zip
Telephone Number
Education
Please provide the following educational information
Last public school attended Grade Is student passing or failing

Scholastic performance (including failures, promotions, grades and attendance)
Conduct
Attendance
Educational Potential (High School Graduate, Vocational, College, GED):
Family History - Mother
Mother's First Name Mother's Middle Name Mother's Last Name
Present address
Home telephone number Date of Birth Place of Birth
Marital Status SSN Occupation/Employer
Serious Illness: Deceased? , if yes, give date
Family History - Father
Father's First Name Father's Middle Name Father's Last Name
Present address
Home telephone number Date of Birth Place of Birth
Marital Status SSN Occupation/Employer
Serious Illness: Deceased? , if yes, give date
Sibling Information
Name: Sex Date of Birth: Address
Name: Sex Date of Birth: Address
Name: Sex Date of Birth: Address
Name: Sex Date of Birth: Address
Visiting Resources
Name:
Address: Telephone Number
Please answer the following questions as completely as possible:

List all previous out-of-home referrals/intervention strategies tried or used

What are the client's presenting problems?

Describe the current family situation

Has the client had any contact with the Juvenile Court? If so, list court location, date, offense, and disposition.

Has the client been referred to a mental health or family counseling clinic? If so, list dates, locations, names of therapist, and diagnoses.

Medication and dosage:

Reason for medication

Medical problems:
Check the behaviors exhibited by the client
Poor Hygiene Verbal abuse Promiscuity
Manipulation Stealing Alcohol use
Poor impulse control Running away Drug use
Lying Fighting Homosexual activity
Prostitution Bed-wetting

Suicide attempts,
if yes number of attempts

Fire starting Destructive Eating Problems
Suicide Talk Shy Temper Outburst
Peer Conflict Withdrawn School performance
Truancy / Drop Out Aggression Sex Offending Behavior
Sexually Abused Physical Abuse Activity Psychic
Aggression towards others or property Anxiety  
Other behaviors
Comments:
Your Name:
Agency or Parent Making Placement

 
 

 

Stepping Stone Family Services Incorporated
 
212 Research Drive | Suite 102 | Chesapeake, VA 23320 | (757) 673.8117 (office) (757) 673.8127 (fax)
Copyright 2009 - Stepping Stone Family Services Inc.