LYFE — LEADING YOUTH FOR EXCELLENCE
STUDENT INTAKE
First Name *
Middle Name
Last Name *
Date of Birth *
Age
Sex *
Select...
Male
Female
Birthplace City *
Birthplace State (2-letter) *
Race *
Select...
African American
Asian
Caucasian
Hispanic
Multi-Racial
Other
Specify Race
Religion *
Height (ft) *
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1
2
3
4
5
6
7
8
Height (in) *
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0
1
2
3
4
5
6
7
8
9
10
11
Weight (lbs) *
Hair Color *
Eye Color *
Phone Number
Unknown
Social Security Number *
Photo (optional)
School
School Name
School District
Grade
Languages Spoken
Placing Agency
Placing Agency
Assigned Worker
Agency Phone *
Dual Involvement
No
Yes
Agency Name
Contact Name
Medical / History
Diagnosis / Concerns (Medical, Mental Health D&A, Sex Offender, ODD, Anxiety, Depression, Etc.)
Medications: Current & Previous
** 30-DAY SUPPLY OF MEDICATION IS REQUIRED PRIOR TO STUDENT ADMISSION **
Medical Records
Upload Most Recent
Medical Records Not Available
Physical Exam
Dental Exam
Psych Evaluation
Other Evaluations
Previous Placements
No Previous Placement
Charges / Legal: Current & Previous
Family
Mother - First Name
Mother - Last Name
Check If Guardian
Phone Number
Unknown
Language
Unknown
Marital Status
Select...
Single
Married
Divorced
Widowed
Separated
Unknown
Mother - Address
City
State
2-letter
Zip Code
+ Add to Visitors
+ Add to Phones
Father - First Name
Father - Last Name
Check If Guardian
Phone Number
Unknown
Language
Unknown
Marital Status
Select...
Single
Married
Divorced
Widowed
Separated
Unknown
Father - Address
City
State
2-letter
Zip Code
+ Add to Visitors
+ Add to Phones
Guardian - First Name
Guardian - Last Name
No Guardian
Relationship
Phone Number
Unknown
Language
Unknown
Guardian - Address
City
State
2-letter
Zip Code
+ Add to Visitors
+ Add to Phones
Approved Visitors (at least one)
First Name
Last Name
Relation
Remove
+ Add Visitor
Phone Contacts (at least one)
First Name
Last Name
Relation
Phone Number
Remove
+ Add Phone
Arrival
Arrival Date
Arrival Time
Insurance
Insurance Provider *
Policy # *
Insurance Card (optional)
Signature
Type Full Name (Signature)
Title (e.g., Caseworker, Agency Staff, etc.)
Placing Agency
Signature Date
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LYFE — Secure Student Intake
