Preliminary Information Form       Please note that this form is not an application for admission, but is provided to allow you to share a brief summary of the child's situation and history.       Information About Person Making Referral   First Name   Last Name   Title   Address   Email   Daytime Phone   Home Phone     Information About Child   First Name   Last Name   Home Address   Current Address   Phone   Age   DOB   Sex M F     Please provide a brief summary of the child's situation including: the presenting problem, placement history, legal history, any psychological diagnoses, and educational testing results.