Student Name:
	Date:	

Address:
				
DOB:
		SSN:		
Sex:    ⬜Female    ⬜Male    ⬜Other		Was your child adopted?                  ⬜Yes     ⬜No  		

Mother/Guardian’s Name:
		
Does this person have custody of the child?                                                                 ⬜Yes     ⬜No 

If yes, a copy of the custody agreement may be required if offered admission to the program		
Address:
		
Phone:
	Work Phone:	
Email:

Father/Guardian’s Name:
		
Does this person have custody of the child?                                                                 ⬜Yes     ⬜No 

If yes, a copy of the custody agreement may be required if offered admission to the program		
Address:
		
Phone:
	Work Phone:	
Email:
		
Education
Last school attended:
			
Does the child have an IEP or receive special education services?                             ⬜Yes     ⬜No			
Current Grade:
	Estimated IQ:		

Medical History
Please describe the applicant’s general health:

Date of last physical:
	Current medications:	
Allergies:
		
Does the child have a history of epileptic or convulsive disorder?                                ⬜Yes     ⬜No		
Does the child have any medical problems and/or handicaps that might interfere with full participation in our program?                                                                                                             ⬜Yes     ⬜No		

Legal History
Has the child been involved with juvenile authorities?                                                  ⬜Yes     ⬜No	
If yes, please provide details:

Is the child currently on probation?                                                                               ⬜Yes     ⬜No	

Substance Abuse History
Has the child used controlled substances?                                                                   ⬜Yes     ⬜No	
If yes, please list types and frequency of use:

Presenting Problem
What recent events or behaviors brought about your request for enrollment?

	
Please describe what you hope Lafayette School can accomplish for the child:

	

Family Therapy
If offered a placement, do you consent to monthly therapy sessions?    ⬜Yes ⬜No	
If offered a placement, how would you like to participate in the monthly family therapy sessions?

⬜In-person    

⬜ Virtually: Zoom, GoogleMeet, WebEx, etc)
                              
⬜Over the phone   

⬜Other: 

Referral
How did you find out about Lafayette School?

Why are you looking for a new school?

	

Treatment History
Facility:
	
Dates of treatment:
	
Name of treating professional:
	
Type of treatment:   ⬜Hospitalization   ⬜Out-patient    ⬜Day treatment    ⬜Substance abuse
                              
  ⬜Under care of psychiatrist    ⬜Under care of psychologist    ⬜Other:	

Facility:
	
Dates of treatment:
	
Name of treating professional:
	
Type of treatment:   ⬜Hospitalization   ⬜Out-patient    ⬜Day treatment    ⬜Substance abuse
                              
  ⬜Under care of psychiatrist    ⬜Under care of psychologist    ⬜Other:	

Facility:
	
Dates of treatment:
	
Name of treating professional:
	
Type of treatment:   ⬜Hospitalization   ⬜Out-patient    ⬜Day treatment    ⬜Substance abuse
                              
  ⬜Under care of psychiatrist    ⬜Under care of psychologist    ⬜Other:	

Please Submit the Following:
1.	All recent psychological/psychiatric diagnostic evaluations from the last 3 years
2.	Previous treatment reports, including hospital admission/discharge reports
3.	School reports from most recent school placement
4.	IEP	

Prosess
1.	Submit application with most recent IEP, Report card, incident reports, discharge summary and any other relevant information 
2.	Schedule a virtual or in-person tour; Lafayette thoroughly reviews the application
3.	Schedule a virtual or in-person interview with ED and therapist/teacher
4.	Staff review of all information, which may include reaching out to family for clarification
5.	A decision is communicated to the family as soon as possible
●	If appropriate, enrollment process begins
●	If not appropriate, recommendations will be made 	

Submission
Please send the completed application and accompanying information 

By mail:  Lafayette School
               Attn: Jennifer O’Malley, Executive Director
               103 Zion Station Road
               Troy, VA 22974

By email: jomalley@mylafayetteschool.org

Please call the school with any questions:  (434)589-2370