Child Intake Form - Arizonans for Children

CHILD INFORMATION (TO BE COMPLETED BY CUSTODIAL PARENT ONLY)

Child’s Last Name

First Name

Date of birth

Age

Gender

Male Female

Current Height

Current Weight

Does your child/adolescent have any drug/food allergies

Yes No

Guardians Name

Where is child placed?

Foster Home Relative Residential Other

Street Address

City

State

Zip Code

Child’s School

Child’s Grade

Child’s Ethnicity

PARENT INFORMATION

Parent Name

Street Address

City

State

Zip Code

Date of Birth

Home Phone

Mobile Phone

Work Phone

Relationship to Child

Marital Status

Employment Status

Employer

Year, Make, Model and color of Parents Vehicle

License Plate Number

Parents Ethnicity

HEALTH/MEDICAL HISTORY

Primary Care Physician/Pediatrician/Counsellor

Phone Number

Are child(ren)’s immunizations up to date?

Yes No Don't Know

Is child taking any medication? (Prescription and over-thecounter)

Yes No

Child’s Name

Medication

Purpose

Child’s Name

Medication

Purpose

Child’s Name

Medication

Purpose

LOGISTICS

How long have the children been in their current placement? Why were the children removed?

What are the abuse allegations? Who is the alleged perpetrator of the abuse?

Are there any topics that should not be discussed during a visit?

Does either parent have any physical or mental health issues?

Does either parent have any substance abuse or violence issues that may be of concern?

Are there any cultural, ethnic, or religious considerations that may help staff better prepare for visits?

Are there any security concerns or additional comments that should be noted?

LEGAL INFORMATION

Name of Attorney

Attorney’s Phone Number

Are there a restraining order in place currently against either participating adult?

Yes No

Has there ever been a restraining order against either parent?

Yes No

Has your child/adolescent ever had involvement with the legal system?

Yes No

Are there any legal problems having to do with other family members?

Yes No

Name

Signature

I certify that is my signature

Date