Dorm 3 Certificate - DOC

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					                              5-DAY CHECKLIST
Student Name: ________________               Dorm: __________________________
Date of Birth: __________________            Worker/Title: _____________________
Juvenile #: ____________________             Worker/Title: _____________________
Jurisdiction: ___________________            Case Manager: ___________________
Legal Status: __________________             Primary Counselor: ________________
Date of Admission: _____________             Date File Received on Dorm: ________
Projected Discharge: ____________            Date Completed: __________________

                    Initial staffing date/time: __________________

Please check student’s file for the following:

Consent Forms__________                      Court Order_____________
Placement Agreement_____                     IME Authorization_____________
Social Security Card______                   Birth Certificate__________
Medical Insurance information________        Haz-Mat _______________
Eagle Intake ______________                   Worker’s email address       _________


          Please send completed copies and updated copies of this form to:
  Education Department, Inventory/Accounting, Nursing Department, and Chemical Dependency

ATTEMPTS TO CONTACT WORKER(S) OR LEGAL GUARDIAN/PARENT(S):
  Date   Time       Message Left: Identify the person’s name or voice mail info.
                                      WORKER QUESTIONS
                Name of person answering the questions: __________________________
                      Regarding (student’s name): ________________________


     NO CONTACT WITH:            RELATIONSHIP:                 REASON (Co-offender, etc.):
1.
2.
3.
4.
5.
6.
7.
         REMEMBER: Clarinda Academy can not restrict contact with student’s immediate
        family (parents, step-parents, grandparents or siblings) unless we have a court order in
         hand. There are no exceptions. We must notify workers and/or parents/legal guardians
                                  of any changes to the no contact list.
1.      Can parent/legal guardian add names to the “no-contact” list? Yes___ No___

2.      Is English the primary family language? Yes___ No___: __________________

3.      What official charges are included in this student’s delinquent history?
        _______________________                       _______________________
        _______________________                       _______________________

4.      Does he/she have any pending charges? No___ Yes ___ Date of hearing: ________
        If yes, what are they? ___________________________________________________

5.      Strengths of the student?                                  Weaknesses/concern areas?
        _______________________                                    _______________________
        _______________________                                    _______________________
        _______________________                                    _______________________
        _______________________                                    _______________________

6.      What goals would you like to see this student accomplish while at Clarinda Academy?
        ____________________________________________________________________
        ____________________________________________________________________

7.      If authorized, what would you like to have addressed in individual sessions? ___________
        ________________________________________________________________________
        ________________________________________________________________________

8.      Does the student have a clothing allowance? No___ Yes___ How Much?___
        If No, do the parents provide clothing? Yes___ No___ DHS? Yes___ No___
        If specific circumstances, explain: ________________________________.

9.      What educational tracking does the student need to pursue? (check one)
        High School: ________          GED: ______ (must be 17 years of age in Iowa and have a
        court order if he is 16 years or under).
        Where will this child be returning to school?______________________________________
        If GED is an option, do you approve of this student earning his GED?_____ (if yes, please
        sign attached permission form which is required prior to the student enrolling in GED classes,
        if not, please disregard form).
10.   Does the student have Special Education needs? Yes___ No___
      If yes, what does he/she receive services for? __________________________

11.   Does the student have restitution? Yes___ No___ Amount: $ _________
      Community Service?:                Yes___ No___ Amount: # ____(hours)
      When restitution is earned, who needs to receive the checks and/or
      documentation?        _____________________ (name to be on check)
                            _____________________ (address)
                            _____________________ (city/state/zip)

12.   Does the student have any children? Yes ___ No ___

13.   When is his/her next scheduled court hearing? Date: ___________ Time: _____
      Location: _____________      Does he/she need to be present? Yes___ No____

14.   Is there a need for Chemical Dependency Treatment? Yes___ No____
      Has CD Treatment been court-ordered? Yes___ No____
      What substances has this student been known to be involved with and/or have they received
      treatment in the past?______________________________________________________
      ________________________________________________________________________

15.   Do you give permission for random UA’s to be drawn upon the student’s return from home
      passes? Yes___ No___

16.   Is he/she involved in gang activity? Yes___ No___
      Additional comments: ____________________________________________________
      ______________________________________________________________________

17.   What mental health diagnoses has this student received from past evaluations? ______
      ______________________________________________________________________

18.   Will this student have probation upon discharge? Yes___ No___
      Clarinda Academy Aftercare (Iowa/Michigan students)? Yes___ No___

19.   We provide students with the opportunity to contact workers/attorneys a minimum of once per
      week. Exceptions can be made if another day or time is more convenient.
             Would you like to request other arrangements? Yes __No__
             If yes, what would those arrangements be? _______________________________

20.   Clarinda Academy provides students with transportation for three passes per year of stay
      (home passes recommended after student has earned Eagle status and consistently
      maintained this for approximately 6-8 weeks); additional passes can be arranged at
      expense of worker or parent. Is this an area of concern? _______

21.   Do you approve of Clarinda Academy taking your student out-of state (most frequently to
      Omaha, NE; Kansas City, KS and MO; and Maryville, MO) on various outings and day trips
      such as movies, museums, amusement parks, or athletic/sporting events on the assumption
      that they will be in Clarinda Academy staff custody at all times?* Yes _______ No_______
      * You will be notified by the Case Manager of any unexpected or non-routine situations which
      require interstate travel and/or of trips which require over-night arrangements.

22.   Do you use e-mail? Yes/No If yes, what is your e-mail address:_______________________
       LEGAL GUARDIAN/PARENT QUESTIONS
                        Name of person answering the questions:_____________________
                           Regarding (student’s name): ________________________

          1. Are there any individuals, other than immediate family, you specifically want on your child’s
             “no-contact” list?
                 We cannot prevent contact with immediate family unless we have a court order
                 Review the list of individuals noted by the student’s worker.
                 The student’s worker gives final approval and/or disapproval (if needed).
                 Clarinda Academy can make recommendations to the worker about a student’s “no-contact” list if
                  there are issues with mail/phone contact, i.e., student is consistently upset after reading a letter,
                  gang writing, etc.
      NO CONTACT WITH:                 RELATIONSHIP:                        REASON (Co-offender, etc.):
 1.
 2.
 3.
 4.
 5.
 6.

2.     Does your child have any special medical problems that we need to be aware of in order to provide
       proper medical attention? ___________________________________________________________
       ________________________________________________________________________________
       Allergies_________________________________________________________________________
       Medications_______________________________________________________________________

3.     Does your child have a Chemical Dependency problem? Yes___ No___
       If yes, please specify what substances and extent of use (to your knowledge) __________________
       ________________________________________________________________________________
       ________________________________________________________________________________

4.     Is your child a member of a gang? Yes___ No___
       If yes, what gang and what was the extent of involvement?_________________________________
       ________________________________________________________________________________

5.     What behavioral issues would you like your child to be working on while at Clarinda Academy and/or
       what would you like him/her to accomplish prior to discharge?
       ________________________________________________________________________________
       ________________________________________________________________________________
       ________________________________________________________________________________

6.     Strengths of your child?                                          Weaknesses/concern areas?
       _______________________                                           _______________________
       _______________________                                           _______________________
       _______________________                                           _______________________
       _______________________                                           _______________________

7.     How long has it been since your child lived in your home?___________________________________

8.     What were your child's responsibilities in the home? _______________________________________
       ________________________________________________________________________________
9.    How did he/she react when asked to help around the house? ______________________________
      ________________________________________________________________________________

10.   How was his/her general behavior in the home? _________________________________________
      ________________________________________________________________________________

11.   What kind of relationship do you have with your child? ____________________________________
      ________________________________________________________________________________

12.   Are there any significant relationship concerns with either parent or siblings? ___________________
      ________________________________________________________________________________

13.   Does your child have any children?____________________________________________________

14.   Will your child be returning to your home after discharge? Yes___ No___
      If no, where is he/she planning to reside? ______________________________________________

15.   Would you like your child to be involved in Clarinda Academy Aftercare (Iowa and Michigan students
      only)? Yes___ No___

16.   What is the maiden name of student’s mother? _______________________ (needed for records).
        A photocopy of student’s birth certificate and copy of social security card is needed for our
         records.

17    Clarinda Academy provides students with transportation for a maximum of three passes per year of
      stay (home passes recommended after student has earned Eagle status and consistently maintained
      this for approximately 6-8 weeks); additional passes can be arranged at expense of worker or parent.
      Is this an area of concern? _______

18.   Where will this child be returning to school?______________________________________
      If GED is an option, do you approve of this student earning his GED?_____ (If yes, the student must
      be 17 years old; however, he must have a court order if he is 16 years or under. Please sign
      attached permission form which is required prior to the student enrolling in GED classes, if not,
      please disregard form).

19.    What plans do you have for your child when he returns to your care (such as having a job, going to
      school, participating in sports/athletics, extracurricular activities, etc)?
      ________________________________________________________________________________
      _______________________________________________________________________________

19.   Do you use e-mail? If so, what is your e-mail address? ______________________________

20.   Do you approve of Clarinda Academy taking your child out-of state (most frequently to Omaha, NE;
      Kansas City, KS and MO; and Maryville, MO) on various outings and day trips such as movies,
      museums, amusement parks, or athletic/sporting events on the assumption that they will be in
      Clarinda Academy staff custody at all times?* Yes _______ No_______
      * You will be notified by the Case Manager of any unexpected or non-routine situations which require
      interstate travel and/or of trips which require over-night arrangements.

Additional Comments _______________________________________________________
_________________________________________________________________________
_________________________________________________________________________

				
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Description: Dorm 3 Certificate document sample