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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.

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Screening Questions

1. Is the child currently hostile/aggressive/combative?
2. Is the child currently under the influence of drugs and/or alcohol?
3. Is the child currently exhibiting suicidal thoughts, or does s/he have a history of self-harming behavior?
4. Is the child charged with any crimes of a sexual nature?
5. Does the child have any history of sexually acting out behavior?
6. Is the child currently charged with any crimes against another person?
7. Does the child have any health conditions that require monitoring?
8. Does the child have any special dietary needs/allergies?
9. Does the child have a history of running away?
10. Does the child have trouble performing daily hygiene tasks independently?
11. Are there any other safety issues that staff need to be aware of?
12. Is the child on any medications?

Contact Information
Whom may the child contact while at NFHFC?

Contact 1

Contact 2
Not required*

Contact 3
Not required*

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

Agency Contact Information

Referring Agency Case Worker

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

Contact 1

Contact 2
Not required*

Contact 3
Not required*

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.

Thanks for submitting!

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