Please feel free to contact Michelle Swanson, Admissions Director, at email@example.com or at 701-872-3745 if you have any questions.
The links below contain all of the information from the Home On The Range Admissions/Referral Packet. All forms are in Portable Document Format (PDF).
Admissions Information for Parents and Youth contains general information and no paperwork/forms that need to be completed and returned.
HOTR Release Of Information
This form specifies who should receive reports generated by Home On The Range (ie; Individual Plan of Care, Quarterly Reports, Discharge summaries, etc). Typically this is who is required to get court orders such as the parent(s) and the placing worker.
Drug and Alcohol Release Of Information
This form allows our Licensed Addiction Counselors to release the Chemical Dependency evaluation to those specified on the form.
Archway Release Of Information
This form allows Archway Mental Health Services to release info from the psychiatrist and/or psychologist directly to the placing worker. The “Release to” line should include the referring worker and agency address, NOT Home On The Range. Please initial “Psychiatric/Psychological”.
This is to document what services the family will be involved in while the child is receiving services at Home On The Range. In addition to services in the community for the family, the Strengthening Family Workshops at Home On The Range may also be included.
Health Tracks Form
Health Tracks*– our nurse is required to perform a Health Tracks Health History on all new residents at Home On The Range. Completion of the information on the form is not required but your signature is necessary on the very last line. This authorizes our nurse to complete the Health Tracks Health History on the resident.
*The Health Tracks form is required prior to, or at the time of admission.
Other Admissions Forms
- Universal Application
- Placement Agreement
- Contract For Services
- 7 Challenges Movie Form
- Animal Assisted NDSU Consent Form
- Animal Therapy Consent
- Church Preference Form
- Climbing Wall Consent
- Evacuation Plan Resident
- HIPPA Consent
- Medical Release
- Telephone & Visitation Info Sheet
If you were successfully discharged from Home On The Range, you may be eligible to apply for an education grant. This grant may be used for vocational, college or university enrollment. For more information and the application, please click on the Fraternal Order of Eagles Memorial Foundation Scholarship Forms that follow. The completed forms, application and necessary paperwork can be mailed to Home On The Range. Home On The Range will verify resident’s admission and discharge dates, and then send the packet to the Memorial Foundation. The forms follow:
- Memorial Foundation Scholarship Information Sheet
- Application for Education Assistance Form
- Educational Assistance Request Form
- Student Authorization
- Family Tax Information Form
- Home on the Range Authorization Form
Some forms require Adobe Acrobat Reader
Download here —
forms updated January 4, 2013