Application for Admission to The Summerhouse

Applicant's Information

Full Name

Address

Phone

Date of Birth

Sex

Height

Weight

Disability/Diagnosis

Ethnic Background

Language(s) spoken at home

Ideal Start Date at Summerhouse Houston?

Parent/Guardian Information

First Parent/Guardian

Full Name

Home Phone

Cell Phone

This address will receive a confirmation email

Address

Occupation/Company

Work Phone

Second Parent/Guardian

Full Name

Home Phone

Cell Phone

This address will receive a confirmation email

Address

Occupation/Company

Work Phone

Previous or Current Academic Settings and Programs

Please select all settings/situations in which applicant has participated

Day Program Employment Private School Public School State School Group/Family Care Home Independent Living Situation Other

Program History

Most recent program in which applicant was (or is currently) enrolled

Program Name:

Start Date

End Date (Today if currently enrolled)

Type (See Above)

Person to contact for more info

Contact's Phone

Contact's Email

Reason for leaving (N/A if still enrolled)

Program in which applicant was previously enrolled

Program Name

Start Date

End Date

Type (See Above)

Person to contact for more info

Contact's Phone

Contact's Email

Reason for leaving

Program in which applicant was previously enrolled

Program Name

Start Date

End Date

Type (See above)

Person to contact for more info

Contact's Phone

Contact's Email

Reason for leaving

Tuition Policy

· Tuition (5 days/week/year round) - $1,872/month
· Friday Activity Fee of $25/week
· Annual activity fee $100

Payment is due in full prior to or on the 5th of each month. Unless prior arrangements have been confirmed with the Executive Director of The Summerhouse, a late fee of $5/day will apply if tuition is not paid by the 5th of each month. A $100 supply fee is due at the time of enrollment.
We do accept CLASS, HCS and TxHml funds that may fund part of the tuition. Please call for details. All members are required to have eligibility for employment services determined by the Texas Workforce Commission.

By entering my full name, I acknowledge that I have read, understand, and agree to the financial commitment I will incur upon my applicant’s acceptance to The Summerhouse.

Does the applicant have a Medicaid waiver?

Yes No

If yes, what type?

HCS CLASS TxHml Not known

Applicant Background

Please answer the following questions with as much candid detail as is possible to allow the Admissions Committee to support an informed decision that supports the needs of your child.

Describe his/her general health including special medical problems or physical disabilities:

Describe his/her communication abilities and style:

Describe his/her social/emotional state MOST of the time (withdrawn, hyper-verbal, even-tempered, etc.):

Are there particular triggers that dramatically alter the social/emotional state described above?

Describe his/her preferred social state (with peers, family, alone, with particular people):

Describe his/her self-help skills (what most others do daily to help him/her):

Is he/she independent in using the restroom?

Does he/she have a tendency of wandering off?

Describe his/her daily routine as well as leisure activities:

Describe his/her aptitudes, interests, and strengths:

Does he/she ever exhibit aggressive or injurious behavior such as hitting, pinching, biting, screaming to him/herself or others? Describe if applicable:

Describe activities and situations that he/she strongly dislikes. How does he/she express this dislike?

Describe your goals and expectations for him/her. What do you hope The Summerhouse can accomplish?

Medical History

Does the applicant have any food, medication, or environmental allergies?

Yes No

If yes, what substances? Please describe reaction and treatment plan.

Summerhouse Houston does not have on-site or on-call nursing staff, therefore we do not administer medications. Whenever possible, medication times should be arranged so that the member does not need to take medication during program hours. In the event that this is not possible, the member must self-administer the medication.

Summerhouse Houston is not responsible for medication administration. However, staff members will:
• Provide locked storage space for medication
• Provide reminders to a member that it is time for his/her medication and retrieve the medication from the locked storage
• Let parent/guardian know if the member refuses/forgets to take medication

In the event that there is an emergency, please list all medications being taken by applicant. Include NAME, DOSE/FREQUENCY, PRESCRIBER, DATE PRESCRIBED

Please share any additional information that could influence the ability of The Summerhouse to work successfully with the applicant and ensure their care, health, and well-being while enrolled in our program.

By entering my full name, I acknowledge that the health and medical information provided above is correct to the best of my knowledge.

Review and Agreement

Please note that the application and all supplemental materials must be submitted in full before it can be reviewed by the Admissions Committee.

It is the policy of Summerhouse Houston to enroll clients of any race, color, and national or ethnic origin. At this time we are not able to accept individuals who display physical or verbal aggression, individuals who are not independent in toileting, those with health issues necessitating medical/nursing care during program hours, or anyone who requires extensive 1/1 assistance. Admission to Summerhouse Houston is not determined by diagnosis; rather it is based upon an individual's willingness to learn, ability to work towards employment and/or service to the community, and ability to function in a group setting.
All information submitted as a part of this application will remain confidential and will be used for the sole purpose of determining admission. No portion of this application information will be shared with any parties outside of Summerhouse Houston.
Please review and sign once all application content has been confirmed and completed. Each candidate is evaluated individually, and we review suitability on a case-by-case basis. Accurate and complete information regarding the applicant’s background, abilities and needs is required to make an accurate assessment. We ask that parents/guardians complete the application thoroughly and candidly. Additional information may be requested from a third party who has served as a therapist, teacher or aid within the past 12 months. A visit to Summerhouse Houston will be scheduled where the applicant will participate in routine daily activities to determine his or her ability to benefit from our program.

We, the undersigned, do give our permission for Summerhouse Houston to contact any and all of the references, programs, schools, and professionals listed in this application.

By entering my full name, I affirm that the preceding information is a complete and accurate statement of all the facts and circumstances relative to the application for enrollment in Summerhouse Houston. FIRST PARENT/GUARDIAN:

Recent Photo of Applicant

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Medical History

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Most recent psychological and/or psychiatric evaluation

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Most recent educational evaluation

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Behavior Plan

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Any additional attachments

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Application for Admission to The Summerhouse

Description

Please Fix the Following