ADMISSIONS PRE-APPLICATION Northwest Academy
Parental Assessment of the Student
Describe the student's current behavior at home, your explanation for this behavior (your opinion), and how long this behavior has persisted.
Please provide any information about your family that would be helpful in assessing the student's needs, including family history and relationships.
If student is not living with the biological parents, please explain why and describe the student's relationship and communication with the biological parents.
Describe any traumatic events or major changes in the student's life.
Describe the student's relationships with peers.
Describe the student's willingness to accept responsibility.
Describe the student's methods for expressing anger and disappointment.
Describe your goals for the student.
List the student 's positive qualities, interests, and accomplishments.
Has the student ever experienced or exhibited any of the following? (If yes, please provide specific details.)
Arson or fire setting? Yes No Date Police Intervention? Yes No
Explain
Cruelty to animals? Yes No Date
Explain
Drug and/or alcohol use? Yes No (If yes, please describe type, if known, and frequency: experimental, moderate, or heavy)
Explain
Self-abusive behavior? Yes No Date Medical intervention required? Yes No
Explain
Suicide discussion, threat or attempt? Yes No Date Medical intervention required? Yes No
Explain
Assaultive/aggressive behavior? Yes No Date (If yes, please describe toward whom: parents, other adults, siblings, peers)
Explain
Police intervention? Yes No Date
Explain
Running away? Yes No Date (How many times and for how long?)
Explain
Did the student contact you while away? Yes No
Explain
Eating disorder? Yes No Date (If yes, please explain and list any medical intervention)
Explain
Sexual activity? Yes No Date
Explain
Physical/sexual abuse? Yes No Date If yes, was there a witness to the abuse? Yes No
Explain
Describe the student's attitude toward and performance in school, including current and prior schools.
How long has this behavior persisted?
Held back a grade, expelled or withdrawn from school? Yes No Date
Explain
Has the student been diagnosed with learning difficulties? Yes No
Explain
Have any academic/creative/intellectual strengths been identified? Yes No
Explain
Has the student ever taken any special education classes? Yes No Date
Explain
Does the student have an individualized education plan (IEP)? Yes No (If yes, please include the most recent IEP with this application.)
Describe any sudden shifts in academic performance. When did these occur? Are you aware of any precipitating factors?
Academic Records Release
Please list all middle, junior and senior high schools the Student attended (most recent first) with complete addresses and phone numbers. (If additional space is needed, please use additional sheets.)
Currently or last enrolled at:
Name of School:
Dates attended: Highest grade completed :
Address
City : State : Zip :
Telephone : Fax :
If not currently enrolled, last date attended : Current grade :
Name of School :
Dates attended : Highest grade completed :
Address
City : State : Zip :
Telephone : Fax :
If not currently enrolled, last date attended : Current grade :
Name of School :
Dates attended : Highest grade completed :
Address
City : State : Zip :
Telephone : Fax :
If not currently enrolled, last date attended : Current grade :
Name of School
Dates attended : Highest grade completed :
Address
City : State : Zip :
Telephone : Fax :
If not currently enrolled, last date attended : Current grade :
Name of School
Dates attended : Highest grade completed :
Address
City : State : Zip :
Telephone : Fax :
If not currently enrolled, last date attended : Current grade :
I/We hereby grant permission to release school transcripts to IES for the Student. Permission is granted to release the following records: official transcript of credit, withdrawal grades including incomplete classes, special education records, IEPs, test data, health records, disciplinary records, counseling information and records pertaining to psychiatric or psychological evaluations.
Parent/Guardian Name : Date :
Signature :
Member Of
Northwest Association of Accredited Schools
National Association of Therapeutic Schools and Programs (NATSAP)
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