GCIS Online Submission | New Foundations Home for Children

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Online Submission – GCIS After Hours Admission Form

To be used by a qualified referring agency when making a referral to GCIS or PW after hours. Form is sent directly to Admissions Director and the Senior Director.

Child's First/Middle Name

Child's Last Name

Street Address

Street Address Line 2

City

State

Postal / Zip code

Phone

Child's Gender

Height - Feet

Hair Color

Date of Birth

Race/Cultural Background

Height - Inches

SSN

Medicaid Number

Screening Questions

1. Is the child currently hostile/aggressive/combative?

Yes

2. Is the child currently under the influence of drugs and/or alcohol?

Yes

3. Is the child currently exhibiting suicidal thoughts, or does s/he have a history of self-harming behavior?

Yes

4. Is the child charged with any crimes of a sexual nature?

Yes

5. Does the child have any history of sexually acting out behavior?

Yes

6. Is the child currently charged with any crimes against another person?

Yes

7. Does the child have any health conditions that require monitoring?

Yes

8. Does the child have any special dietary needs/allergies?

Yes

9. Does the child have a history of running away?

Yes

10. Does the child have trouble performing daily hygiene tasks independently?

Yes

11. Are there any other safety issues that staff need to be aware of?

Yes

12. Is the child on any medications?

Yes

Contact Information
Whom may the child contact while at NFHFC?

Contact 1

Name

Phone Number

Relationship to Child

Contact 2
Not required*

Name

Phone Number

Relationship to Child

Contact 3
Not required*

Name

Phone Number

Relationship to Child

Contact Information
Is there anyone the child may NOT contact while at NFHFC?

Name

Relationship to Child

Name

Relationship to Child

Name

Relationship to Child

Agency Contact Information

Referring Agency Case Worker

First Name

Last Name

Case Worker's Phone Number

Referring Agency

Emergency Contact Information
In case of emergency, whom should be contacted?

Contact 1

Name

Phone Number

Relationship to Child

Pager/Cell

Contact 2
Not required*

Name

Phone Number

Relationship to Child

Pager/Cell

Contact 3
Not required*

Name

Phone Number

Relationship to Child

Pager/Cell

Authorization

As an official of the State of South Carolina or a duly authorized law enforcement official acting on behalf of an agent of the State of South Carolina, or as the child's legal guardian, I hereby authorize placement at New Foundations Home for Children for this child.

Type your full name to confirm.

Thanks for submitting!