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Child Intake Form
A child intake form is required for each child. The parent the child lives with will complete and submit this form.
All fields of this form must be completed.
If a question does not apply to your child, please write "N/A".
Full name of child
Date of birth
Current grade level:
What languages does the child speak?
Does your child have any drug/food allergies? If yes, please specify
Does your child have any medical issues we should be aware of? If yes, please specify
Name of child's primary care physician:
Is the child taking any medication? If yes, list below:
Name of parent requiring supervision as it appears on the court order:
Name of parent the child lives with as it appears on the court order:
Are there any topics that should not be discussed
as outlined in the court order
Is the child involved or has the child ever been involved with the legal system for any other reason? If so, please explain:
When was the last time that the parent that is court ordered for visitation saw the child in person? Was it supervised? If so, by whom?
Does the child have phone contact with the parent that is ordered supervised visitation?
How will the child respond at the first visit?
Will a service animal be present for this child?
I certify that is my signature