• Child-Focused Care Application

    Child-Focused Care Application

  • This application is for CHILDREN AGES 6-17 needing placement.

    Please note, OBHC is currently limited to accepting children from Oklahoma, Arkansas, Kansas, Missouri and Texas.

    If you are a single mother with children, please use the Family Focused Care Initial Application.

  • Thank you for taking the time to apply to OBHC.

    Unfortunately, we are unable to accept your application at this time because our program is currently limited to children residing in Oklahoma, Arkansas, Kansas, Missouri, and Texas.

     

  • General Information

  • Location Preference

    Indicating your placement location preference will help us best direct your application.

    Selecting "No Location Preference/First Available" here will automatically send your application to both locations accepting your child's gender. Please do not submit an application to multiple locations. 

  • Which location would you prefer?*
  • Relationship to Child*

  • Format: (000) 000-0000.

  • Legal Custody/Guardian Information
    Who has legal custody of the child?

  • Format: (000) 000-0000.

  • Child Information

    Beginning with this section, all requested information is about the child. (not the person completing the application)

  • Date of Birth*
     - -
  • Child Gender*
  • Has the child experienced any of the following? (Please select all that apply)*

  • Medical Information

  • Does the child have any physical limitations?*

  • Aggression/Violence Tendencies

  • Is child verbally or physically aggressive?*
  • Has the aggression resulted in a physical confrontation or injury to another person?*
  • Were there weapons involved?*
  • Has the child been involved with law enforcement or juvenile?*
  • Please check any that child has been involved with:*

  • Drugs, Alcohol and Tobacco Usage

  • Does the child use substances?*
  • If yes, what types? (Check all that apply.)
  • Has the child ever been suspended or legally charged for possession or distribution of a substance?*

  • Behavioral Issues

  • Has the child ever run away or left home without permission?*
  • Does the child steal? *
  • Sexual Activities: (Check any that apply.)*

  • Psychological History

  • Emotional Issues

  • Does child fail to show shame or guilt for his/her negative behavior?*

  • Suicidal Thoughts

  • Has the child made suicidal comments or threats?*
  • Has the child attempted suicide?*
  • Has the child ever intentionally hurt themselves? (Ex: cutting, head banging, etc.)*
  • Has child been seen by a professional counselor?*
  • Has the child ever received inpatient health treatment?*
  • Does the child experience hallucinations/delusions?*

  • Educational History

  • Has the child failed any grade?*
  • Does the child have an Individualized Education Plan (IEP) for Specialized Educational Services?*
  • Is there a problem with school attendance?*
  • Has the child ever been placed in detention, suspended or expelled?*

  • Trauma, Grief/Loss

  • What types of trauma has this child experienced? (Check all that apply.)*

  • Notification Preference

  • Once your application is received and we have had the opportunity to review it, the campus will give you an initial contact with information. This is how we keep you informed of the process. Please indicate below the best way for us to contact you with the information regarding this application.

  • Preference*
  • Follow-Up Contact Preference
  • Should be Empty: