Adolescent Therapeutic Group Home | Gateway Homes

Gateway Homes operates 24 hours a day, 7 days a week and is licensed by the Department of Behavioral Health and Developmental Services. Our Therapeutic Group Home provides a structured environment for male residents ages 14 to 17 who are facing behavioral and emotional challenges. Our dedicated staff helps residents develop daily living skills, fosters a sense of responsibility, and promotes self-sufficiency. Residents will focus on enhancing their socialization, education, vocational skills, and behavior management to achieve success in all areas of life.

Exclusionary Criteria for this group home includes:

Individuals diagnosed with an intellectual disability or developmental disability
Individuals who are actively suicidal, psychotic, or homicidal
Individuals who require inpatient, medically monitored detoxification services
Individuals younger than age 14
Individuals who require medical care beyond the capabilities of the program which could include daily nursing services, specialized medical/nursing procedures, specialized medical devices, specialized feeding services, etc.
Individuals required to register on the Sex Offender registry or have not completed Sex Offender Treatment Programs
Individuals convicted of violent crimes

Please provide the following when applicable:

Custody order
Current behavior treatment plan
Educational records and most recent school transcripts / Current IEP
Psychological (and/or other applicable testing)
Medical records, including current insurance information
Current physical (not older than 90 days or within the last 12 months if transferring from another state-licensed facility)
Current dental exam, completed within the last 12 months
Current Immunization record
Progress notes and discharge summaries from past placements
Legal history and involvement

The following will be used to determine eligibility:

Application
Criteria for admission
Supporting documentation

Please upload any supporting documentation with the application. Any questions or assistance please email Amanda Tevis at Atevis@gatewayhomes.org or call 1-804-910-6735.

Application for Adolescent Group Home Program

General

Application Date:

Tour Date:

Adolescent Name:

Last

Adolescent First Name

First

Adolescent Middle Name

Middle

Address:

City

State

Zip

Phone Number:

Social Security Number:

Gender Identity:

Please describe Other Ethnicity

Age:

Birthdate

Birthplace:

City/Town, State

Country:

(If not USA)

Clinical Information

Current Diagnosis:

Current Medication:

Do you believe that you have behavioral health challenges and would benefit from treatment in a structured environment?

Yes

If yes, please describe the types of behavioral health challenges (e.g., the triggers for episodes, what staff can do to help you when you are having an episode, and what you can do to help cope with these episodes):

Are you currently receiving mental health services through a Community Services Board or other provider?

Yes

If yes, please list the name and contact of each provider:

List any current medical conditions and allergies (include ALL allergies) that you have:

Immunizations/Vaccines Received (attach copy of immunization records):

Diphtheria, Tetanus, & Pertussis (DTaP, DTP, or Tdap)

Yes

Partial

Comments

Hepatitis B

Yes

Partial

Comments

Human Papillomavirus (HPV)

Yes

Partial

Comments

Measles, Mumps, & Rubella (MMRP)

Yes

Partial

Comments

Polio

Yes

Partial

Comments

Varicella (Chickenpox)

Yes

Partial

Comments

List any operations or surgeries that you have had including dates:

Have you experienced any of the following?

Seizures

Yes

Fainting Spells

Yes

Head Injury

Yes

Protection Needs

Which of the following protection needs do you need? (check all that apply)

Protection from self-inflicted harm to self

Protection from harm due to inability to care for self

Protection from harm due to being in an unsafe or unstable environment

Protection from harm due to physical, sexual, or emotional abuse by a parent or caregiver

Protection from harm due to the behaviors of siblings or others who live in the home

Other

Please describe Other Protection Needs

Educational/Vocational/Social

What grade are you currently in?

Do you receive any special education service or an IEP?

Yes

If so, please briefly describe your accommodations:

How many times have you been suspended/expelled from school in the last year?

If applicable, please provide details regarding each suspension/expulsion:

What are your educational goals?

Graduate High School, and (if applicable):

Attend College

Attend a technical training program

Earn a GED

Drop out of high school as soon as possible

I don't know

What are your favorite and least favorite classes in school?

List any past employment experiences and the dates of employment:

Please use this space to let the clinical team know any other information about you that you would like to share:

Contact Information

Guardian Contact Name:

Contact's Phone Number:

Contact's Address:

City

State

Zip

Benefit/Financial Information

Funding Source:

Contact Information:

I certify that the information provided within this application and its’ attached documents is both complete and accurate.

Signature of Applicant:

Clear

Date:

Signature of Parent/Guardian:

Clear

Date

Please upload your supporting documentation here to send with your application:

Maximum file size: 5MB

If you are human, leave this field blank.

Exclusionary Criteria for this group home includes:

Please provide the following when applicable:

The following will be used to determine eligibility:

General

Clinical Information

Psychiatric History

Please indicate applicable behavioral concerns, either now or in the past:

Immunizations/Vaccines Received (attach copy of immunization records):

Have you experienced any of the following?

Daily Living

Protection Needs

Educational/Vocational/Social

Legal Information

Contact Information

Benefit/Financial Information

I certify that the information provided within this application and its’ attached documents is both complete and accurate.

Application for Admission

Exclusionary Criteria for this group home includes:

Please provide the following when applicable:

The following will be used to determine eligibility:

General

Clinical Information

Psychiatric History

Please indicate applicable behavioral concerns, either now or in the past:

Immunizations/Vaccines Received (attach copy of immunization records):

Have you experienced any of the following?

Daily Living

Protection Needs

Educational/Vocational/Social

Legal Information

Contact Information

Benefit/Financial Information

I certify that the information provided within this application and its’ attached documents is both complete and accurate.