Heartlight Admissions Application

Please allow up to one (1) hour to complete this application. If you need to take a break and come back, please use the “save and finish later” button so you don’t lose your progress. If you have any questions, please feel free to give us a call.

Give Us A Call - (903) 668-2173

Please attach a current picture of your child(Required)

Drop files here or

Max. file size: 256 MB, Max. files: 1.

Your Name(Required)

Your Email(Required)

Name of Child(Required)

Relationship To Child(Required)

Date(Required)

Applicant Information

Child's Age(Required)

Birthplace(Required)

Birthdate(Required)

Current Grade Level(Required)

Gender(Required)

Ethnicity(Required)

Is this your natural child, or adopted child?(Required)

Natural

Adopted

Adoption Date(Required)

Religious Affiliation (or Denomination)(Required)

Is your child presently living at home?(Required)

Yes

If no, please explain.(Required)

Has your child had previous placements outside the home?(Required)

Yes

If yes, please list other programs, schools, hospital or other institutions, along with estimated dates.(Required)

Parents Information

If deceased, please note date and cause.

Father's Name

Father's Birthdate

Father's Address

Mobile Phone

Other Phone

Occupation

Highest Grade Completed

Religious Affiliation (or Denomination)

Mother's Name

Mother's Birthdate

Mother's Address

Mobile Phone

Other Phone

Occupation

Highest Grade Completed

Religious Affiliation (or Denomination)

Who currently has custody of this child?

Father & Mother

Father

Mother

Stepparent(s)

Grandparent(s)

Someone Else

Please explain

Does the child have stepparents?

Yes

Stepfather’s Name

Stepfather’s Age

Stepfather’s Address

Mobile Phone

Other Phone

Occupation

Highest Grade Completed

Religious Affiliation (or Denomination)

Stepmother’s Name

Stepmother’s Age

Stepmother’s Address

Mobile Phone

Other Phone

Occupation

Highest Grade Completed

Religious Affiliation (or Denomination)

Please give the following information for each member of your family who lives in your home and/or immediate family members:

Name

Age

Relation

Living With

Person to Notify in case of an emergency

First Last

Phone

Social History

Birth to six years old:(Required)

Six to Twelve:(Required)

Twelve to present:(Required)

Present Problems

What are your child’s current behavioral problems?(Required)

What are your child’s current emotional problems?(Required)

What is currently being done about these problems?(Required)

Family Relationship

Please describe your child’s past and present relationship with:

Father:(Required)

Mother:(Required)

Stepfather:(Required)

Stepmother:(Required)

Siblings:(Required)

Please describe any other significant relationships with family members you child may have:(Required)

Is there any history of emotional, medical, or physical problems in the family?(Required)

Yes

Please explain(Required)

Divorce/Separation History

Are parent’s divorced(Required)

Yes

Pending or Separated

If yes, when?(Required)

How old was you child at the time?(Required)

How has the divorce been an issue for your child?(Required)

Have there been any past or current divorce/custody battles?(Required)

Yes

Please explain(Required)

Have the parents remarried?(Required)

Yes

To who, and when?(Required)

Has the remarriage been an issue for you child?(Required)

Yes

Please explain(Required)

Has the child or family had history of relocation?(Required)

Yes

Please explain the reason for relocation(Required)

What kind of effect have this had on your son/daughter?(Required)

Adoption

Was your son/daughter adopted?(Required)

Yes

Adoption Date(Required)

Where was your child adopted from?(Required)

Did your child have any previous adoption homes?(Required)

If yes, how many?(Required)

Were there any special circumstances leading up to the adoption? Explain:(Required)

Has the adoption been an issue for your child?(Required)

Do they know information about their biological parents?(Required)

Have the biological parents been involved?(Required)

If so, how and when?(Required)

Behavioral History

Has you child ever demonstrated aggressive or violent behavior?(Required)

If yes, please explain:(Required)

Has your child had any involvement with the legal system?(Required)

If yes, please explain:(Required)

Has your child ever talked about, threatened, or tried to commit suicide?(Required)

If yes, please explain:(Required)

Does your child have a history of self-harm?(Required)

If yes, please explain:(Required)

Has your child had any changes in behavior and/or mood? (sad, anxious, withdrawn, angry, etc.)(Required)

If yes, please explain:(Required)

When did these changes occur?(Required)

Has your child had any abnormal thoughts?(Required)

Yes

If yes, please explain:(Required)

Please describe the history of any specific disorder (depression, behavioral, eating disorders, etc.) that your child has had:(Required)

Please check any of the following characteristics that applied to your child growing up.(Required)

Has your child ever run away?(Required)

Yes

If yes, please answer the following questions:(Required)

# of times

When

Alone?

With whom?

How long was your child gone?(Required)

Did your child telephone home?(Required)

Distance traveled(Required)

City(Required)

State(Required)

Did your child stay with relatives?(Required)

Yes

Did your child stay with friends?(Required)

Yes

How were his/her needs met (stealing, pan-handling, friends, other)?(Required)

What was the reason for running away?(Required)

Explain circumstances of your child’s return home:(Required)

Was your child involved in illegal activities?(Required)

Yes

If yes, describe in detail:(Required)

Runaway Information

Hair Color(Required)

Eye Color(Required)

Birthmarks, Scars, Tattoos(Required)

Please list any friends or relatives your child might try to contact. If known, please include phone numbers.(Required)

Social Relationships

Does your child have difficulty making friends?(Required)

Yes

Does your child prefer to be alone?(Required)

Yes

Does your child get along well with others?(Required)

Yes

Does your child have more friends his or her own age, older, or younger?(Required)

Own age

Older

Younger

Mix of all

Does your child have more friends of the same sex, or the opposite sex?(Required)

Same sex

Opposite sex

Mix of both

Has your child recently changed friend groups, or stopped hanging out with long time friends?(Required)

Yes

What type of peer group(s) does your child spend time with?(Required)

What are your feelings about these choices?(Required)

Sexual History

To your knowledge has your child been sexually active?(Required)

Yes

If yes, please describe history, frequency, patterns, births, abortions, etc.(Required)

To your knowledge has your child had any sexual problems?(Required)

Yes

Has your child exhibited any inappropriate sexual behavior (i.e. sexual acting out or perpetration)?(Required)

Yes

If yes, please explain:(Required)

Has your child exhibited any gender identity issues?(Required)

Yes

If yes, please explain:(Required)

To your knowledge has your child ever been sexually abused or raped?(Required)

Yes

If yes, please explain:(Required)

History of Sexual, Physical or Emotional Abuse

Has your child experienced sexual, physical or emotional abuse?(Required)

Yes

Was your child a victim, offender, or both?(Required)

Victim

Offender

Both

For each area listed below, please describe any applicable history of relevant abuse, including dates, duration, frequency and treatment.

Incest:(Required)

Rape:(Required)

Molestation:(Required)

Sexual Perpetration:(Required)

Physical Abuse:(Required)

Verbal or Emotional Abuse:(Required)

Neglect:(Required)

Legal measures taken:(Required)

Child’s behavior, attitude and defense exhibited:(Required)

Degree of family involvement in the child’s abuse treatment:(Required)

Substance Abuse Use

Has your child ever used tobacco, drugs or alcohol?(Required)

Yes

If yes, please describe history, usage, frequency, types, interventions, and when they last used.(Required)

Family history of substance abuse:(Required)

Please describe current substance use in the home, including tobacco and alcohol.(Required)

Medical Information

Medical Information(Required)

Name

Nature of Services

Age when seen

Please list all doctors and other professionals (i.e. general physicians, psychiatrist, psychologists, education, etc.) who have examined and or treated your child (please use additional paper if needed):

Medication

Allergies(Required)

Please list any past/present medications(Required)

Medication

Doctor

Reason

Dates

Family Therapy

To adequately understand the parent/child relationship and its impact on the child, it is very important that we know of any family therapy. Please list all psychiatric, psychological and/or marriage and family therapy in which the family members have participated:(Required)

Name(s) of Therapist(Required)

Frequency(Required)

Duration(Required)

Family member participation:(Required)

Father

Mother

Child

Siblings

Additional Information

Have there been any unusual circumstances in the child’s life, which have been hard for him/her to accept?(Required)

Have there been any deaths of family or friends that have greatly impacted your child?(Required)

What does your child believe his current problem to be?(Required)

What do you see as your child’s estimated length of stay?(Required)

What are your expectations of placement at Heartlight?(Required)

How do you plan to be involved in your child’s growth while he/she is at Heartlight?(Required)

What is your child’s perception of being placed at Heartlight?(Required)

What do you see as your child's (and ultimately, your family's) goal of sending him or her to Heartlight?(Required)

In the space below, please include any other pertinent information which would be helpful to our Staff in understanding your current situation, or which would help us in our assessment of your family’s participation in the Heartlight program.(Required)

Strengths And Needs

What are your child’s special needs and strengths in each of the following areas:

Physical Needs:(Required)

Physical Strengths:(Required)

Familial Needs:(Required)

Familial Strengths:(Required)

Educational Needs:(Required)

Educational Strengths:(Required)

Spiritual Needs:(Required)

Spiritual Strengths:(Required)

Social Needs:(Required)

Social Strengths:(Required)

Psychological Needs:(Required)

Psychological Strengths:(Required)

Educational History

Please describe your child’s school performance (grades, relationship with teachers, classroom behavior):

Kindergarten to 6th grade:(Required)

Junior High School (7th and 8th grade):(Required)

High School (9th – 12th grades):(Required)

Has your child had difficulties in school?(Required)

Yes

If yes, what?(Required)

Has your child ever received any type of remedial instruction?(Required)

Yes

If yes, which grades and classes? Please explain.(Required)

Has your child ever had an IEP (Individualized Educational Plan) or special education placement (resource room, content mastery, etc)?(Required)

Yes

If so, please attach any assessment information

Drop files here or

Max. file size: 256 MB.

Has your child ever been diagnosed with ADD or ADHD?(Required)

Yes

Does your child suffer from poor eyesight, hearing loss, speech impediment, etc?(Required)

Yes

If yes, please explain.(Required)

Has your child ever repeated grades?(Required)

Yes

If yes, which ones?(Required)

Has your child ever skipped grades?(Required)

Yes

If yes, which ones?(Required)

Has your child ever been suspended or expelled?(Required)

Yes

If yes, when?(Required)

Please explain.(Required)

School Attendance

School

Grade

Year

Reason for leaving

Current Grade(Required)

Still attending?(Required)

Yes

Last grade completed(Required)

Name of current school(Required)

Phone(Required)

School Address(Required)

Street Address Address Line 2 City State ZIP Code

School Counselor(Required)

First Last

What do you perceive as your child’s current academic needs?(Required)

If your child is in high school, please attach their transcripts and/or home school graduation requirements. Otherwise, please attach their current grade card.

Drop files here or

Max. file size: 256 MB.

Heartlight Admissions Application Fee(Required)

The $300 application fee is non-refundable. Should your child be accepted into the Heartlight program, the application fee will be applied to the first month’s tuition.

Price:

Credit or Debit Card(Required)