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The Westfield Day School

Student Application

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Student Information

Student Name *

Preferred Name

Date of Birth *

Student Cell

Student Email

Home Address *

City *

State *

Zip Code *

Parent Information

Mother's Information

Mother's Name

Cell Phone

Home Phone

Address (if different from student)

Email

Occupation

Father's Information

Father's Name

Cell Phone

Home Phone

Address (if different from student)

Email

Occupation

Previous Diagnosis Information

In order for us to fully assess the student's needs, we encourage parents to include relevant records of the School and Mental Health history. If you need help obtaining copies of documents please contact the office of The Westfield Day School, 914-273-6222.

Previous Diagnosis Info

Treating Doctor/Office Name

Please have the school send: Evaluations (Psych Ed, Neuropsych) and IEPs to The Westfield Day School at 1 North Greenwich Road, Armonk, NY 10504 or email to info@westfielddayschool.org

Current Treatment

Is the student presently enrolled in therapy?

Yes No

Therapist Name, Phone & How Long in treatment

Psychiatrist Name, Phone & How Long in treatment

Is the student currently taking medication?

Yes No

If yes, please list all medications and dosages

Educational History

Does the student have an IEP?

Yes No

If yes, what is the educational (CSE) Classification? (e.g. LD, ED, OHI, Autism, etc.)

School District of Residence

CSE Contact Name and Phone Number

Has the student ever attended The Westfield Day School before?

Yes No

If yes, dates attended

Funding

Is the student's tuition to be funded by the school district or by the family?

School District Family Not sure yet

If funded by school district, which district?

Information About the Student

Please check all items that relate to this student (check all that apply):

Aggression Anxiety Attachment Issues Attention Problems Autism Spectrum Bipolar Disorder Cutting/Self-Harm Depression Eating Disorder Executive Function Issues Gender Identity Issues Grief/Loss Learning Disabilities Low Self-Esteem Mood Dysregulation OCD Oppositional Behavior Panic Attacks PTSD School Refusal Social Skills Deficits Substance Use Suicidal Ideation Trauma History

Other (please specify)

Additional Questions

Has the student experienced a traumatic event?

Yes No

If yes, please explain

Has suicide ever been considered or attempted?

Yes No

If yes, please explain

Has the student ever been hospitalized for psychiatric reasons?

Yes No

If yes, please explain (where, when, duration)

Is the student adopted?

Yes No

Are the student's parents separated or divorced?

Yes No

If yes, please describe custody arrangement

Why are you interested in The Westfield Day School?

How did you hear about The Westfield Day School?

Signature

Today's Date *

Signature (Type Full Name) *

I certify that all information provided is true and accurate to the best of my knowledge. *

Emergency Contact

Emergency Contact Name

Relationship to Student

Phone Number

Insurance Information

Name of Insurance Carrier

ID #

Group #

Name on Policy

Policyholder Date of Birth

Policyholder Employer

Questions? Call us at (914) 273-6222

The Westfield Day School, a therapeutic school for students in grades 7-12, was founded in Rye, New York, in 2000.

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1 North Greenwich Road
Armonk, New York 10504

frontdeskwestfield@gmail.com

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