Epworth Village, Inc. Referral Process
In order for referrals to receive our fullest consideration, the materials should be as complete and accurate as possible.
Please click on the links below to download a copy of both the Application for Admissions and Health Care Questionnaires Part I and II. Fill out and send to:
Epworth Village, Inc.
In addition to the Application for Admission, and Health Care Questionnaire we will also need the following information if available:
Psychiatric Diagnoses and/or psychological evaluation
Current IQ test scores
Family social history
Out-of-home placement history (if any)
Law Violations (if any)
Court reviews and most current court order (if any)
NDHHS or social services case plan (if any)
Current verification of handicapping condition (or eligible for verification)
Current Individual Educational Program (IEP) (if any)
Discharge summaries from past agencies and placements
Copy of Birth Certificate
Copy of Immunization Records
Other information as requested
Following receipt of the information requested, a determination regarding a pre-placement interview will be made. Please feel free to contact me if you have any questions concerning the application process.
1-(402) 362-3353 ext. 1134
fax: 1-(402) 363-7821