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About Falcon Ridge
Team
Campus
Tour
Meet Our Horses
Testimonials
Programs
Clinical
Equine Therapy Program
Falcon Ridge Ranch Therapeutic Model
Academic Excellence Program
Admissions
Online Application
Careers
Contact Us
Online Admissions Application
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Falcon Ridge Ranch Admissions
Online Admissions Application
Name of person referring the youth
First
Last
Date of referral
MM slash DD slash YYYY
Name of referring agency
Phone
Youth's name
First
Last
Gender
Age
DOB
MM slash DD slash YYYY
Is the youth receiving Special Education services?
Yes
No
Youth’s current location
State ID/Title 19 #
Parent/guardian name
First
Last
Parent/guardian phone number
Funding source for treatment of the youth
Does the youth have Medicaid coverage?
Yes
No
Youth's most current IQ score
Youth's most current diagnosis
Axis I
Axis II
Axis III – Current medical issues and diagnosis
List all current medications and dosage
History of most recent treatment services
Agency name
Inpatient or outpatient?
Inpatient
Outpatient
Does the youth demonstrate escalating problems of self-harm or assaultive behaviors as evidenced by
Suicidal ideations and/or threat to self or other?
Yes
No
Current self-harm behaviors?
Yes
No
Evidence of physical aggressions to self or others?
Yes
No
Please send all questions and referral information to:
lance.harkey@rop.com or call: 435-256-7500
A clinical decision cannot be made until collateral documentation is received. Collateral information can include, but is not limited to:
- Predisposition reports including a list of current and previous charges
- Current and past placement progress and discharge reports
- Recent psychological or psychiatric evaluations including diagnosis and full-scale IQ score
All information is handled securely and is not available to any third parties.
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