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If you are interested in Tipton Academy, please call our admissions line at 877-968-8443

A Positive Place for Change 877-968-8443

If you are interested in Tipton Academy, please call 877-968-8443 or fill out the following form and send it to our admissions office.

It is important to be complete and thorough when filling out the from so that we can assess whether or not our program would be a good fit for your child.

Student Assessment Form

Parent Information

First name:

Last name

Relationship to child:

Address

City

State

Zip code

Contact Information

Contact phone

Second contact phone

E-mail address

Student information

Student First name:

Student Last name

Height

Weight

Age

Date of Birth

Student Details

Student assessment information. It is important that we have a clear overall picture of the sorts of acting out that you are dealing with. The fields below are a guideline as to the the issues that we need to know about in order to assess your child. Please use the notes section to provide information that does not fit into one of the following categories.

Substance abuse

Legal problems, police interaction

Family situation

Academic situation

psychological(add, adhd, etc)

Suicide threats, self harm

Running away, sneaking out

Levels of aggression, defiance

Additonal notes

Additonal notes

This form will be sent to Tipton Academy Admissions

Name:



Mail: