Sunbelt Christian Youth Ranch

I NEED HELP! Please call me about my child!

To allow our staff to have more information prior to our initial contact, please complete this form. This form is not an official application, but will assist us. We will contact you as soon as possible to discuss your circumstances.

Child's Name

Your Name
Address
City, State, Zip
Phone Number
Cell Phone

Your E-mail

What is your relationship to this Child? Are you a parent or guardian?

Child's Date of Birth: My Child's Gender:

Does your Child have any Physical Handicap? Please describe:

What type of behavior does your child exhibit?
Please check all the boxes that apply.

	Defiance toward authority figures
	Poor/declining relationship with family members
	Lack of self-esteem and/or confidence
	Out of control behavior in the home, school, and/or community
	Emotional outbursts/inability to channel anger appropriately
	Poor personal motivation
	Emotional immaturity
	More concerned with possessions than with people
	Social phobias
	Running Away
	Truancy or lack of participation in educational opportunities
	Underachieving
	Minor delinquencies or legal offenses
	AD(H)D- Attention Deficit Disorder with or without the hyperactivity
	ODD- Oppositional Defiant Disorder
	Non-psychotic depression
	Low ego strength
	Impulsive behavior
	Lying/manipulative action
	Stealing and/or lack of respect for property of others
	Experimentation with drugs and/or alcohol
	Poor interpersonal skills
	Choosing a negative peer group/easily influenced by friends
	Treatment Resistant
	History of violent episodes that have required physical or medical restraint
	A need for substance abuse detoxification
	Serious criminal charges
	Sexual Offender
	Long history of serious drug/alcohol abuse
	Pregnancy---Past
	Pregnancy---Currently
	Major medical problems
	A psychiatric condition that has not been controlled with medication
	History of or substantial potential for suicidal attempt
	Schizophrenic or sociopath personality disorders
	Very poor physical condition or physical impairments
	Obesity
	Intelligent Quotients (IQ) below 80
	Check this box if you child is a victim of sexual abuse

Is your child currently involved in a legal situation, criminal or civil? Please describe the circumstances:

What has prompted you to seek help from a residential program?

Does your Child Attend School?

If your child attends school, What grade is he/she in?

Has your child ever been placed before in a residential program before? Describe the efforts that you have made in the past to get control of the situation?

How does your child feel about a Residential program? Have you discussed this?

Does your family attend a church? If so, how often?

How quickly do you anticipate needing to make a placement into a residential program?

How did you hear about Sunbelt Christian Youth Ranch?

Is there anything you need to tell us that we didn't ask?

After you submit the form, you will have to use your BACK BUTTON to return to the website.

We will contact you as soon as possible to discuss your circumstances so that
we can evaluate whether or not we will be able to accept your child.

Sunbelt Christian Youth Ranch
8782 Old Highway 80 | Lake, Mississippi | 39092
601-775-3498

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