Child Intake Form

CHILD INFORMATION

The parent the child lives with will complete and submit this form. If you are not the custodial parent, please do not fill out this form.

Full name of child

Gender

Male Female

Date of birth

Age

Current grade level:

Current height:

Current weight:

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:

Yes No

Medication(s)

Purpose

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?

Please describe:

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?

Any concerns/questions:

Name

Email Address

Signature

I certify that is my signature

Date