Admissions Application

A Place of Second Chances

We understand that seeking help for your child is a significant decision.

Our admissions process is designed to help determine whether Lighthouse Children’s Home is the right fit.

Before You Apply

Before filling out the Admissions Application, please make sure that you and your child meet the following requirements for our program:



Minimum 12-Month Program

The child must be able to complete the full 12-months before turning 18.



Parent/Guardian Support

Success happens through family support and cooperation.



Financial Participation

Families must financially contribute to their child’s care.

Our Admissions Process

Before filling out the Admissions Application, please make sure that you and your child meet the following requirements for our program:



Complete Residential Application

Tell us about your family and child.



Complete Education Application

Provide academic history and learning needs.

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Admission Review

Each application is carefully reviewed to determine eligibility for a Family Interview.



Family Interview

We will set a time for an in-person family interview with our staff.

THIS IS A PERMANENT RECORD.

All questions must be answered and answered truthfully. Giving false or misleading information and/or omitting information pertinent to the child may cause the child to either not be approved for the program or to be expelled from the Lighthouse Children’s Home if approved and the information is revealed after admission. If information is unknown, every effort should be made to obtain it. This record will be very valuable in working with the child. If a question is not applicable, please mark N/A.

If you have any questions or need help, please call us at: 850-877-3778.

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- Step 1 of 2

Parent/Guardian Information

Name *

First

Middle

Last

Email *

Confirm Email

Primary Phone *

Secondary Phone (optional)

Address *

Address Line 1

City

State

Zip Code

Parent/Guardian Employment Information

My employment status: *

Employed Full-Time
Employed Part-Time
Self-Employed
Homemaker
Not currently employed

Place of Employment *

Employer's Phone *

Employer's Address *

Address Line 1

City

State

Zip Code

Applicant's Relationship to the Child

What is your relationship to the child? *

Birth Parent
Adoptive Parent
Step Parent
Guardian
Other

Please explain your relationship to the child: *

When did you gain custody of the child? *

Do you have legal authority to place the child? *

Which of these apply: *

Sole Custody
Joint Custody
Temporary Custody

Please briefly explain the temporary arrangement: *

List Other Individual With Legal Custody Rights

Name *

First

Middle

Last

Confirm Email

Primary Phone *

Secondary Phone

Address *

Address Line 1

City

State

Zip Code

What is their relationship to you? *

Husband
Ex-husband
Wife
Ex-Wife
Other

Please explain their relationship to you: *

Other parent/legal guardian employment status: *

Employed Full-Time
Employed Part-Time
Self-Employed
Homemaker
Not currently employed

Place of Employment *

Employer's Phone *

Employer's Address *

Address Line 1

City

State

Zip Code

Other Parent/Guardian Relationship to the Child

What is their relationship to the child? *

Birth Parent
Adoptive Parent
Step Parent
Guardian
Other

Please explain their relationship to the child: *

When did they gain custody of the child? *

Reference

Please list one person who knows both you and the child so we can contact them as a reference.

Reference Name *

First

Last

Reference Email *

Confirm Email

Reference Phone *

Reference Secondary Phone (Optional)

Reference Address *

Address Line 1

City

State

Zip Code

Your Home Church Info

Do you have a home church? *

Does the child attend church with you? *

Child attends
Child does not attend

Are you a member of the church or just attending? *

I'm not a member
I am a member

How long have you been attending this church? *

Church Name *

Pastor's Name *

Church or Pastor's Phone Number *

Church Address *

Address Line 1

City

State

Zip Code

Is your Pastor aware of the situation with your child? *

May we call your Pastor for a reference? *

Information About the Child

The remainder of this application will be information about the child you are wishing to place in our care. Please answer as truthfully and thoroughly as you can.

Child's Name *

First

Middle

Last

Child's Age *

Child's Birthday *

Child's Ethnicity *

Child's ethnicity description: *

Child's Sibling(s)

Does the child have any siblings? *

Please list sibling(s). *

Name, age, & relationship (brother, sister, half-brother, step-sister, etc….)

General Health - Emotional and Mental Condition of the Child

Does this child have any physical disabilities or limitations? *

Please explain: *

There will be an opportunity for longer explanations at the end of this form, if need be.

Has this child ever been suspected of, diagnosed with, and/or received counseling or treatment for any of the following: *

Attention Deficit Disorder (ADD)
Attention Hyperactive Deficit Disorder (ADHD)
Mood disorders
Bipolar
Depression
Oppositional Defiance Disorder (ODD)
Schizophrenia
Post-Traumatic Stress Disorder (PTSD)
Reactive Attachment Disorder (RAD)
Self-harm and/or suicide attempts
Autism/Asperger Syndrome
Eating disorders
Emotional or physical abuse
Sexual abuse and/or rape
Substance abuse
Sleep disorders
Pregnancy
Abortion
None of the above

ADD - Suspected of or Diagnosed? *

ADHD - Suspected of or Diagnosed? *

Mood Disorders - Suspected of or Diagnosed? *

Bipolar - Suspected of or Diagnosed? *

Depression - Suspected of or Diagnosed? *

ODD - Suspected of or Diagnosed? *

Schizophrenia - Suspected of or Diagnosed? *

PTSD - Suspected of or Diagnosed? *

RAD - Suspected of or Diagnosed? *

Self-harm/Suicide Attempts - Suspected of or Diagnosed? *

Autism/Asperger Syndrome - Suspected of or Diagnosed? *

Eating Disorder - Suspected of or Diagnosed? *

Emotional/Physical Abuse - Suspected of or Diagnosed? *

Sexual Abuse/Rape - Suspected of or Diagnosed? *

Substance Abuse - Suspected of or Diagnosed? *

Sleep Disorders - Suspected of or Diagnosed? *

Pregnancy - Past or Current? *

If yes to pregnancy or abortion, please explain: *

There will be an opportunity for longer explanations at the end of this form, if need be.

Please list all current and past counsellors, treatment/therapy centers, physicians, and mental health professionals who have treated any of the above conditions: *

There will be an opportunity for longer explanations at the end of this form, if need be.

Is your child currently on any prescription or over-the-counter medications? *

Medication 1 *

Dosage *

Reason for Medication *

Add another medication? *

Medication 2 *

Dosage *

Reason for Medication *

Add another medication? *

Medication 3 *

Dosage *

Reason for Medication *

Add another medication? *

Medication 4 *

Dosage *

Reason for Medication *

Add another medication? *

Medication 5 *

Dosage *

Reason for Medication *