Referral Page

Our main goal at Children’s Homes is to be able to serve a child or a sibling group that is in need of out of home residential care. Our services are very comprehensive in order to serve today’s troubled youth. Please use the information below to help us better understand the problems of the child(ren) that may need our help. We will review the information and get back to you as soon as possible.

Make a Checkmark by Clicking all that apply on each section below. Please do not forget to Click or press the Submit Button at the bottom of this page to enable our staff to receive this important information.

This is not an Admission Form only a Referral.  If we feel your child will benefit from our program we will send you an Admission Form for you to fill out.

 

 

Presenting Problems for the Child:

Taking Medication  Physical Handicap  Allergies  Sexually Transmitted Disease

HIV  T.B.  Anxiety Disorder  Attention Deficit Hyper Activity  Bi-Polar

Conduct Disorder  Eating Disorder  Depression  Oppositional Defiant

Post Traumatic Stress  Psychotic  Reactive Attachment  Autistic

Suicidal  Sexual Abuse  Physical Abuse  Grief or Loss  Adoption  Divorce

Do you have Medical Insurance Coverage?  Yes  -or-  No

School Problems for the Child:

Struggling with Schoolwork  Behavior Problems  Expelled  Retained

Suspended  Truancy  Learning Disorder  Low IQ

Other:

Behavior Problems for the Child:

Disrespectful  Lying  Negative Peers  Rebellious  Runaway

Physically Aggressive  Sexually Active  Sexually Aggressive  Stealing

Tobacco  Drug Usage  Alcohol Usage  Gang Activity  Trouble with the Law

Child Information:

First Name 
Last Name
Date of Birth
Race
Gender
Legal Guardian
Who is Child Living With?
Name of School
Current Grade

Person Referring this child(ren) to us:

Who told you about us?
First Name
Last Name
E-mail
Address
City
State       Zip
Home Telephone
Work Telephone
Fax 
 Please contact me as soon as possible regarding this matter.
Please include any other needed comments in the space below:

 

Children’s Homes, Inc.

5515 Old Walcott Road, Paragould, AR 72450

Voice: 870.239.4031 • Fax: 870.236.9743

E-mail: Trish Copeland, Asst. Director of Child and Family Services: trishc@childrenshomes.org

Web Site: http://www.childrenshomes.org

You are also welcome to CALL, WRITE or E-MAIL or print and FAX the completed  form if any of these options are more convenient.