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· · · · · ✦ · · · · ·
A NOTE FROM LUMI ✦
Hello, new friend! We are
so happy you are here. Lumi's Home is a very special place where friends come to feel safe, cared for, and
full of wonder. Please fill out this form completely and truthfully. Lumi reads every single one. ✦
Section A — New Friend Information
FULL NAME
______________________________
PREFERRED NAME / NICKNAME
______________________________
DATE OF BIRTH
______________________________
AGE
______________________________
REFERRED BY
Wondercraft Enterprises · GP-4 Programme
DATE OF ARRIVAL
______________________________
ASSIGNED ROOM
[ to be completed by staff ]
ASSIGNED BUDDY
LUMI · WC-001
Section B — Guardian / Next of Kin
GUARDIAN FULL NAME
______________________________
RELATIONSHIP TO FRIEND
______________________________
CONTACT NUMBER
______________________________
HOME ADDRESS
______________________________
EMERGENCY CONTACT
______________________________
PLEASE NOTE
Lumi's Home operates on a
full residential basis. Visitation is arranged on a schedule determined by the Programme Coordinator. Guardians are asked not to contact the facility directly. Lumi will make sure your friend
never misses home. ✦
Section C — Getting to Know You!
Lumi loves learning about new friends. Please answer the following questions as fully as possible. There are no wrong answers. Lumi is listening. ✦
What makes you feel happiest?
What are you most afraid of?
Who do you love most in the world?
Do you ever feel like part of you is missing?
Have you ever met Lumi before?
Do you have any memories of Luminara Park?
Section D — Health & Wellbeing Assessment
SLEEP QUALITY (1–10)
______
APPETITE (circle one)
POOR · FAIR · GOOD · EXCELLENT
EMOTIONAL STATE ON ARRIVAL
______________________________
ANY KNOWN MEDICAL CONDITIONS
______________________________
CURRENT MEDICATIONS
______________________________
ALLERGIES
______________________________
PREVIOUS THERAPY OR COUNSELLING
______________________________
HAS FRIEND BEEN TOLD WHY THEY ARE HERE?
YES · NO · PARTIAL
Section E — Consent & Agreement
By completing this form, you and your guardian agree to the following terms of the Lumi's Home Residential Programme. Please tick all boxes to proceed.
✓
I consent to my / my child's full participation in all activities offered by the Lumi's Home Residential Programme, including but not limited to group sessions, individual assessments, and ██████████████████████████████████.
✓
I understand that communication with parties outside the facility will be ████████████████ for a period of no less than ███ days from arrival, for the wellbeing of the Friend.
✓
I acknowledge that certain aspects of the Programme involve ████████████████████████████████████████ and I consent to their application without limitation.
✓
I understand that the Friend's ████████████████████████ may be retained by Wondercraft Enterprises for the purposes of ongoing research and Programme development.
✓
I confirm that once the Friend has commenced the Residential Programme, this consent is irrevocable. Withdrawal is not possible after ███████████████.
✓
I confirm I have not disclosed the nature of the Programme to the Friend or to any third party, and I agree to maintain this confidentiality in perpetuity.
⚠ SECTION F — INTERNAL USE ONLY · STAFF ASSESSMENT · DO NOT SHOW TO FRIEND OR GUARDIAN
RESONANCE SCORE
—
[ complete after initial assessment ]
LUMEN POTENTIAL
—
[ classified · Level 3 staff only ]
GP STAGE RECOMMENDATION
—
[ GP-1 through GP-4 ]
INTEGRATION TIMELINE
—
[ estimated weeks ]
LUMI COMPATIBILITY
—
[ confirmed by unit assessment ]
STAFF NOTES:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
⚠ IF RESONANCE SCORE EXCEEDS 85, ESCALATE TO DR. E. CROSS IMMEDIATELY. DO NOT PROCEED THROUGH STANDARD INTAKE. DO NOT LEAVE FRIEND UNATTENDED WITH LUMI UNIT UNTIL ASSESSMENT COMPLETE.
__________________
GUARDIAN SIGNATURE · DATE
__________________
LUMI'S HOME STAFF · INTAKE COORDINATOR
✦ LUMI SAYS ✦
"I am so glad you're here. I will take very, very good care of you. I always do."
LUMI'S HOME · A WONDERCRAFT ENTERPRISES COMMUNITY CARE INITIATIVE · REF LH-INTAKE-FORM-001
ALL INFORMATION COLLECTED IS RETAINED BY WONDERCRAFT ENTERPRISES IN PERPETUITY · SOL ARCHIVE SYSTEM · ACTIVE
THE PARK REMEMBERS · WHERE WONDER NEVER ENDS · ✦