Your Information:

Name:

Relation to child:

Email:

Address:

City:

State:

Zip:

Phone:

Work phone:

Cell phone:

Race:

Home church:

Age:

Child's Information:

First name:

Middle name:

Last name:

Gender:

Click To Choose Male Female

Race:

Place of birth:

Age:

Grade:

Height:

Weight:

Eye color:

Click To Choose Blue Green Brown Hazel

Hair color:

Click To Choose Black Brown Blonde Red

Child's insurance:

Click To Choose Covered By Parent's Insurance SoonerCare Other Government Coverage No Insurance

Family type:

Click To Choose Nuclear Family - both biological parents in the home Blended Family - a remarried biological parent in the home Adoptive Family - not related biologically Extended Family - grandparent or other relative as caregiver Single Parent or other

Seeking:

Click To Choose Long Term Placement – Over 2 years Reunification Plan – 1-2 years

How did you hear about Cookson Hills?

Out-Of Home Placement: Please list when, where, why,
and how long your child was placed outside your home.

Drug/alcohol treatment facilities:

Foster Care/State custody:

Residential/Group Home care:

Psychiatric treatment facilities:

Youth shelter:

Juvenile Detention Center:

Other family members:

Friends:

Traumatic Events: Please list when and how long your child
experienced the trauma.

Family separation or divorce:

Death of a loved one:

Subjected to bullying:

Abused by a caregiver/parent:

Neglected by a caregiver/parent:

Sexually abused by a youth:

Witness to abuse of siblings:

Witness to abuse of caregiver:

Participated in abuse investigation:

Medical Issues:

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

1. How often does your child take medications?

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

2. How often is your child ill?

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

3. How often has your child been hospitalized or had surgery?

EXPLAIN any answers above related to your child's medical issues
and list any medications and/or diagnoses.

Academic Behaviours:

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

1. My child is bored at school.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

2. My child is unhappy at school.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

3. My child's grades have gone down.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

4. My child been is flunking classes.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

5. My child is passing but working below potential.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

6. My child fails to do or hand in homework.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

7. My child receives Special Educational Services.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

8. My child skips class.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

9. My child is habitually tardy.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

10. My child has problems with school authorities.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

11. My child disrupts class.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

12. My child destroys school property.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

13. My child is physically aggressive at school.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

14. My child has detentions, suspensions or expulsions.

EXPLAIN any answers above or identify other issues related to your
child's schooling.

Behaviours & Relationships At Home:

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

1. My child has a poor relationship with me.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

2. My child is disrespectful to parental authority.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

3. My child is physically aggressive to me.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

4. My child refuses to participate in family activities.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

5. My child fails to do chores or help with family obligations.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

6. My child steals from family members.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

7. My child leaves without permission or runs away.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

8. My child has a poor relationship with siblings.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

9. My child is physically aggressive with siblings.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

10. My child has a poor relationship with a non-custodial parent.

EXPLAIN any answers above or identify other issues related to your
child's home life.

Spiritual Issues:

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

1. My child questions the existence of a supernatural authority.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

2. My child fails to pray.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

3. My child willfully disobeys God.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

4. My child refuses to participate in church related activities.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

5. My child is involved in occult or alternative spiritual activities.

EXPLAIN any answers above or identify other issues related to your
child's spiritual welfare.

Social Issues:

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

1. My child lacks friends.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

2. My child fails to keep friendships.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

3. My child maintains negative friendships.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

4. My child steals from peers.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

5. My child is physically aggressive with peers.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

6. My child is involved with the juvenile justice system.

EXPLAIN any answers above or identify other issues related to your
child's social life.

EXPLAIN If your child has been in trouble with the law.

Use of Free Time:

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

1. My child gives up on difficult tasks.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

2. My child starts and drops hobbies.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

3. My child abuses tobacco, drugs or alcohol.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

4. My child is sexually active.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

5. My child has forced themselves on another in a sexual way.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

6. My child is involved with pornography or sexual communication.

EXPLAIN any answers above or identify other issues related to your
child's use of free time.

Emotional Issues and Attitudes:

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

1. My child fails to show remorse when confronted.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

2. My child is argumentative.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

3. My child acts without thinking.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

4. My child lies or sneaks around.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

5. My child makes excuses or fails to take responsiblility for behavior.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

6. My child acts like privileges are rights.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

7. My child has threatened or has attempted suicide.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

8. My child cuts, scratches, or burns their skin.

Choose 0 - don't know 1 - never/NA 2 - sometimes 3 - often enough 4 - too often

9. My child has eating issues.

EXPLAIN any answers above or identify other issues related to your
child's emotional issues or attitudes.

Why are you seeking placement at Cookson Hills?

What goals do you have in mind for your child and family?

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