[vc_row][vc_column][vc_custom_heading text=”Online Acceptance Application” font_container=”tag:h1|text_align:left” use_theme_fonts=”yes”][vc_column_text]Pre-qualify your child for Turning Winds Academic Institute.[/vc_column_text][/vc_column][/vc_row][vc_row][vc_column][vc_column_text]

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Parent First Name
Parent Last Name
Nameyour full name
Phone
Street Address
City
State/Province
Zip/Postal Code
Child First Name
Child Last Name
Child Age
Referral DetailsPlease help us say Thank You
Do you have insurance?
We do not accept Medicare/Medicaid at this time
Parent Assessment of Child
Hobbies and Interests of son/daughter
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ReligionPlease list church and/or religious affiliations of your child and family members, if any, and whether they are active or not.
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Parent/Child Relationship
Parent One RelationshipDescribe the relationship with your son or daughter
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Parent Two RelationshipDescribe the relationship with your son or daughter
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Has your child ever run away from home?
How often in last 5 years?
Most Recent Run
For how long?
LocationWhere did your son or daughter run to?
Is your child intelligent but unmotivated?
Intelligent but unmotivatedPlease Explain
Is your child insecure or lacking in confidence?
Insecure or lack of confidencePlease explain
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Does your child exhibit rebelious behavior?
Rebelious behaviorPlease Explain
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Has your child ever been diagnosed with any clinical disorders?(e.g., depression, ADD, ADHD, etc.)
Clinical DisordersPlease explain
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Has your child ever had any involvement with the legal system?
Arrests and convictionsPlease tell us of any and all arrests and convictions with approximate dates
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What Court?
Name and phone number of probation officer
What PERSONAL efforts have been made to resolve these concerns/problems with your child?If none, please type "none"
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What PROFESSIONAL efforts have been made to resolve these concerns/problems with your child?If none, please type "none"
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Professional help informationPlease provide the name, address and telephone number of counselor, dates of visits, purpose of visits, type of treatment, if any, and if they are currently treating your child.
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Has your child ever demonstrated violent or gang related behavior?
Violence or gang related behaviorPlease explain
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Has your child ever talked of, or attempted, suicide?
Please list ATTEMPTS with dates and methods
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Please list DISCUSSIONS with dates and methods
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Has your child shown signs of severe isolation?(e.g., disconnections from self, family, peers, etc.)
Severe isolationPlease explain
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Has your child ever exhibited arson or fire-setting behavior?
Arson or Fire-setting behaviorPlease explain
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Has your child ever exhibited disturbing behavior toward animals or inflicted harm on them?
Animal CrueltyPlease explain
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Has your child ever exhibited self abusive behavior?
Self-abusive behaviorPlease explain
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Has your child ever abused drugs or ever used alcohol?
Under what circumstances?
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Specific drugs usedIf not known then type "not known"
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How often? (socially or alone)
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How long has he/she been using the above-described drugs/alcohol?
How would you rate his/her drug usage?
Are there any other family members (past or present) who have similar problems?
Family members with similar problem
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Has your child been sexually active?
Sexual activityPlease explain
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Has there ever been any abuse (sexual/physical) or other traumatic events in your child's life?
Abuse or traumatic events
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Has your child ever been suspended or expelled from school?
Date of expulsion/suspension
Reason for expulsion/suspension
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Number of previous suspensions
Length of expulsion/suspension
What objectives do you hope to achieve by enrolling your child in Turning Winds Academic Institute?
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