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Parent Portal

Application Form

"*" indicates required fields

GENERAL INFORMATION ABOUT YOUR SON

Are the Guardians divorced*
Is your son adopted*
If one Guardian is sending your son to Liahona Academy, is the other Guardian supportive*
What is the source of funds used to pay for treatment?*

Verification of Benefits

MM slash DD slash YYYY

SUICIDAL

Has your son been suicidal? Explain*

Any verbal expressions of suicide? Explain*

Any physical harm to self? (Such as cutting, eating disorder, etc.) Explain*

Any suicide attempts? Explain*

VIOLENCE

Is your son violent with any other kids, siblings, or property? Explain*

Is your son violent with Parents/Guardians? Explain*

Is your son violent with Authority? Explain*

Has your son run away or attempted to run? Explain*

Does your son come and go as he wants and acts like nothing has happened?*

Does your son take off and the police have to find and bring him back?*

Has your son ever been physically abused? Explain*

MEDICAL

Is your son psychotic, schizophrenic, autistic, Asperger’s? If yes, please explain*

Does your son have any seizures, convulsions or epilepsy?*

Does your son have diabetes?*

Is your son allergic to any medications? If yes, please list them.*

Does your son have any self-medicating issues? Explain*

Does your son use alcohol or marijuana? If yes, is it excessive?*
Is it suspected that your son was exposed prenatally to alcohol or drugs, or been diagnosed with Fetal Alcohol Syndrome?*

LEGAL

Has your son been in trouble with the law? (Give details)*

Has your son ever been arrested?*

Has your son ever been on probation?*

Has your son had any Court dates?*

SCHOOLING

Has your son dropped out of school?*

Has your son been suspended or expelled from school? Explain*

Has your son been failing school? If yes what subjects*

Does your son require any additional help in school?*

Does your son have an IEP or 504 plan? If yes, what subjects?*

Does your son have an IQ below 85?*

THERAPY

Has your son been in counseling or therapy? If yes in what setting and for how long*

Has your son been admitted into any other treatment programs? If yes what programs?*

Has your son attempted to run from other treatment programs?*

SEXUAL

Is your son sexual active?*

Does your son have a boyfriend or girlfriend or lots of partners?*

Has your son experienced any sexual deviancy, porn, or inappropriate behavior with another child?*

Does your son have any inappropriate sexual behavior on the internet or social media?*

Has your son ever been sexually abused?*

Has your son ever been the perpetrator of sexual abuse?*

HEALTH

Are there any allergies or food allergies? If yes please list*

Does your son have any problems with bladder control?*

Does your son have any problems with bed wetting?*

Does your son have any other medical problems? (i.e. brain injury, epilepsy, asthma, broken bones, etc.)*

MISC

Does your son have any history of arson? Explain*

If your son is over 185 lbs., is he athletic or a Couch Potato?*

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Parent Portal