I NEED HELP!  Please call me about my child!

To allow our staff to have more information prior to our initial contact, please complete this form.  This form is not an official application, but will assist us.   We will contact you as soon as possible to discuss your circumstances.


Child's Name



Your Name


City, State, Zip

Phone Number

Cell Phone

Your E-mail


What is your relationship to this Child?  Are you a parent or guardian?

Child's Date of Birth:            My Child's Gender:              

Does your Child have any Physical Handicap?  Please describe:

What type of behavior does your child exhibit? 
Please check all the boxes that apply.

Defiance toward authority figures
Poor/declining relationship with family members
Lack of self-esteem and/or confidence
Out of control behavior in the home, school, and/or community
Emotional outbursts/inability to channel anger appropriately
Poor personal motivation
Emotional immaturity
More concerned with possessions than with people
Social phobias
Running Away
Truancy or lack of participation in educational opportunities
Minor delinquencies or legal offenses
AD(H)D- Attention Deficit Disorder with or without the hyperactivity
ODD- Oppositional Defiant Disorder
Non-psychotic depression
Low ego strength
Impulsive behavior
Lying/manipulative action
Stealing and/or lack of respect for property of others
Experimentation with drugs and/or alcohol
Poor interpersonal skills
Choosing a negative peer group/easily influenced by friends
Treatment Resistant
History of violent episodes that have required physical or medical restraint
A need for substance abuse detoxification
Serious criminal charges
Sexual Offender
Long history of serious drug/alcohol abuse
Major medical problems
A psychiatric condition that has not been controlled with medication
History of or substantial potential for suicidal attempt
Schizophrenic or sociopath personality disorders
Very poor physical condition or physical impairments
Intelligent Quotients (IQ) below 80
Check this box if you child is a victim of sexual abuse

Is your child currently involved in a legal situation, criminal or civil?  Please describe the circumstances:

What has prompted you to seek help from a residential program?

Does your Child Attend School?  

If your child attends school, What grade is he/she in?  

Has your child ever been placed in a residential program before?  Describe the efforts that you have made in the past to get control of the situation?


How does your child feel about a Residential program?  Have you discussed this?

Does your family attend a church?  If so, how often?

How quickly do you anticipate needing to make a placement into a residential program?

How did you hear about Sunbelt Christian Youth Ranch?

Is there anything you need to tell us that we didn't ask?




After you submit the form, you will have to use your BACK BUTTON to return to the website.

We will contact you as soon as possible to discuss your circumstances so that
we can evaluate whether or not we will be able to accept your child. 


Sunbelt Christian Youth Ranch
8782 Old Highway 80
| Lake, Mississippi | 39092

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