CARES Application Form 032708

CARESPROGRAM APPLICATIONCOMPREHENSIVE ADOLESCENT REHABILITATION AND EDUCATION SERVICECHILD AND FAMILY INSTITUTEST. LUKE’S AND ROOSEVELT HOSPITALS432 WEST 58 TH STREET, 9 TH FLOORNEW YORK, NY 10019PHONE: (212) 523-3083FAX: (212) 523-7547REVISED 03.27.2008

CARESPROGRAM SUMMARYThe Comprehensive Adolescent Rehabilitation and Education Service (CARES) at St. Luke's andRoosevelt Hospitals’ Child and Family Institute, in collaboration with the Addiction Institute of NYand the Department of Education’s Restart Division, aims to provide a safe and therapeutic schoolenvironment for New York City public high school students or GED students whose previousschool performance has been limited by emotional and behavioral difficulties. Our program workswith adolescents whose impulsive behaviors, emotional upsets, alcohol and/or drug use, and/orskipping of school have prevented their academic success. CARES combines a small-scaleeducational environment, daily therapy groups, and psychiatric treatment to improve personal andacademic skills.We expect that the students referred to CARES will be motivated to accept help for their academicand personal problems so that they can finish high school or obtain their GED successfully. Agood deal of personal motivation is required by CARES, because it is expected that each student willattend classes and treatment groups at school 5 days per week, and that each student will participatein weekly psychotherapy sessions and family meetings. In the past, many students have stayed in theprogram to graduation, while others have returned to a regular school after a period of time. Bothoptions are possible. Just remember that your success will require regular program attendance andhard work.The CARES program provides an open, respectful, and safe learning environment. Physicalaggression, provocative behavior, and excessive truancy are not tolerated. Students who cannotabide by these policies are dismissed. CARES is a Regents Diploma and GED program, so thatreferred teens must have completed the 8th grade successfully prior to applying. The overall goal ofCARES is to provide capable students the support they need for social and academic success. Goodluck with your application!PLEASE NOTE: both “Student Form” and “Referral Form” must be completed in fullin order to be reviewed..

CARESPROGRAM APPLICATIONSTUDENT FORMDear Student,You are applying for a position in CARES, an alternative high school program that combines regular school classes with instruction groups that teachskills to help manage personal relationships and feelings. We are very interested in hearing about you and why you would like to participate in ourprogram. Please answer the questions below as completely as you can. You may use the back of the form for additional writing space, if needed. Welook forward to meeting with you!STUDENT NAME: ____________________________DATE OF BIRTH:____/____/____ TODAY’S DATE:____/____/____1. WHAT NAME DO YOU PREFER TO BE CALLED? __________________________________________________________2. HOW DID YOU HEAR ABOUT THE CARES PROGRAM? ____________________________________________________3. PLEASE WRITE ONE OR TWO PARAGRAPHS TELLING US WHY YOU WANT TO BE IN THE CARES PROGRAM.4. PLEASE TELL US SOMETHING ABOUT YOUR INTERESTS AND YOUR PLANS FOR LIFE AFTER HIGH SCHOOL.5. LIST THE THREE BIGGEST PROBLEMS THAT HAVE MADE IT HARD FOR YOU TO ATTEND HIGH SCHOOL:PROBLEM #1: _____________________________________________________________________________________________PROBLEM #2: _____________________________________________________________________________________________PROBLEM #3: _____________________________________________________________________________________________6. HOW DO YOU PLAN TO OVERCOME THESE PROBLEMS SO THAT YOU CAN ATTEND PROGRAM EVERY DAY?PROBLEM #1: _____________________________________________________________________________________________PROBLEM #2: _____________________________________________________________________________________________PROBLEM #3: _____________________________________________________________________________________________7. ARE THERE ANY ADULTS (FAMILY OR FRIENDS) IN YOUR LIFE NOW WHOM YOU CAN TRUST WHEN YOU NEED HELP? IF YES, WHO ARE THEY?8. CARES STUDENTS ARE EXPECTED TO ATTEND CLASSES AND TREATMENT GROUPS AT SCHOOL 5 DAYS PER WEEK, AND TO PARTICIPATE INWEEKLY INDIVIDUAL SESSIONS AND FAMILY MEETINGS. DO YOU AGREE TO FULFILL THIS EXPECTATION?(CIRCLE ONE): YES, I AGREE OR NO, I DON'T AGREESTUDENT SIGNATURE: _________________________________________DATE: ___________________CARES PROGRAM APPLICATION PAGE 1 OF 5.

CARESPROGRAM APPLICATIONREFERRAL FORMPlease note that all items must be completed for this form to be reviewed.1. STUDENT INFORMATIONNAME: ___________________________________________________ DATE OF BIRTH: _____/_____/_____ GENDER:__________ADDRESS:PHONE #:2. PARENT OR LEGAL GUARDIANNAME: ___________________________________________________ RELATIONSHIP TO STUDENT: __________________________ADDRESS:PHONE #:3. WHY DO YOU THINK THIS STUDENT AND HIS OR HER FAMILY IS APPROPRIATE FOR CARES?4. WHAT HAS PREVENTED THE STUDENT FROM SUCCESSFULLY ATTENDING HIGH SCHOOL?5. WHAT OBSTACLES MIGHT HINDER THIS STUDENT AND FAMILY'S ABILITY TO PARTICIPATE IN DAILY CLASSES AND THERAPY GROUPS, AND WEEKLYFAMILY MEETINGS?6. HOW MIGHT THESE OBSTACLES BE OVERCOME?CARES PROGRAM APPLICATION PAGE 2 OF 5.

PSYCHIATRIC INFORMATION7. CURRENT PSYCHOTHERAPISTNAME:ADDRESS:PHONE #8. PSYCHIATRIST OR MEDICATION PRESCRIBER, IF ANYNAME:ADDRESS:PHONE #9. CURRENT MEDICATIONS, IF ANY (NAME, DOSAGE, FREQUENCY)A.B.C.10. DO YOU CURRENTLY HAVE ANY CASE MANAGEMENT SERVICES (ICM, SCM, BCM, WAIVER, ETC.)? IF SO, PROVIDE CONTACT INFO:NAME (AGENCY & WORKER):ADDRESS:PHONE #TYPE OF SERVICE:11. DESCRIBE THE EMOTIONAL AND BEHAVIORAL PROBLEMS OF THIS STUDENT, INCLUDING A HISTORY OF PAST TREATMENTS AND DIAGNOSES.12. DOES THE STUDENT CURRENTLY USE OR HAVE A HISTORY OF ALCOHOL AND/OR DRUG USE? IF SO, PLEASE SPECIFY.13. DOES THE STUDENT HAVE A HISTORY OF PSYCHIATRIC HOSPITALIZATION OR INPATIENT REHABILITATION? IF SO, PLEASE SPECIFY.CARES PROGRAM APPLICATION PAGE 3 OF 5.

MEDICAL INFORMATION14. PEDIATRICIAN OR MEDICAL PROVIDERNAME:ADDRESS:PHONE #15. DESCRIBE THE STUDENT'S MEDICAL PROBLEMS, IF ANY, INCLUDING ANY MEDICATIONS TAKEN.16. THE STUDENT'S LAST PHYSICAL EXAM WAS ON: _____/_____/_____ (MM/DD/YY)ACADEMIC INFORMATION17. MOST RECENT SCHOOLNAME:ADDRESS:PHONE #18A. HIGHEST GRADE COMPLETED: ____________ 18B. HIGH SCHOOL CREDITS EARNED: ________.19. DOES THE STUDENT HAVE A HISTORY OF ACADEMIC DIFFICULTIES, INCLUDING LEARNING DISORDERS? IF SO, PLEASE SPECIFY.20. DOES STUDENT HAVE AN INDIVIDUALIZED EDUCATION PLAN (I.E.P.) THROUGH THE DEPARTMENT OF EDUCATION? _______YES21. DAYS OF SCHOOL MISSED IN PAST 6 MONTHS (ESTIMATE # OR %) : _____________________NO22. INSURANCE INFORMATION (PLEASE CHECK ALL THAT APPLY)MEDICAID? _______YES _______NO MEDICAID #MEDICAID MANAGED CARE? _______YES _______NO COMPANYOTHER INSURANCE?_______YES _______NOIF YES, WHAT TYPE?_____________________________________ GROUP #NAME OF PERSON INSURED:______________________________ SS # OF PERSON INSURED:_______-______-_______CARES PROGRAM APPLICATION PAGE 4 OF 5.

REFERRAL AGREEMENT: PLEASE READ AND THEN SIGN BELOWI, the undersigned, am referring the student described above for consideration by the CARES program. I understandthat this referral must be screened by the CARES Clinical Team prior to any further application procedures, and thatboth an intake with student and guardian and educational testing must occur before an admission decision is made. Iunderstand that Admission to the CARES program begins with a 30-day probation period in which the programreserves the right to return clinical and academic responsibility for the new student back to the previous providers ifthe student does not meet an adequate level of participation.SIGNATURE: ___________________________________________________PRINTED NAME: ________________________________________________DATE: ___________________PHONE #: _______________TITLE/RELATION TO STUDENT: ______________________________________HOW DID YOU HEAR ABOUT THE CARES PROGRAM?DOCUMENTATION REQUIREDThe following documents will be required in order for a student to be fully enrolled in the CARES program. Thesedocuments may be submitted with this application, or brought by the student and parent/guardian to the intakeevaluation.Please indicate status of each document listed at the time of application:Included withapplication□□□□□□□To be brought tointake evaluation□□□□□□□COPY OF PARENT’S PHOTO IDENTIFICATION(or copy of STUDENT’S PHOTO IDENTIFICATION if 18 or older)COPY OF STUDENT’S BIRTH CERTIFICATECOPY OF STUDENT’S SOCIAL SECURITY CARDSTUDENT’S SCHOOL TRANSCRIPTS (not needed if student is incoming 9 th grader)(Report Cards may occasionally be substituted if transcripts prove difficult to obtain)COPY OF STUDENT’S INDIVIDUALIZED EDUCATION PLAN (I.E.P.) if applicableSTUDENT’S IMMUNIZATION RECORDWRITTEN RECORD OF STUDENT’S PHYSICAL EXAM WITHIN PAST 6 MONTHSCARES PROGRAM APPLICATION PAGE 5 OF 5.