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Child Intake Form
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CHILD INFORMATION
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
*
Gender
*
Male
Female
Date of birth
*
Age
*
Current grade level:
*
Current height:
*
Current weight:
*
What languages does the child speak?
*
HEALTH/MEDICAL HISTORY
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
*
PARENT INFORMATION
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
*
Signature
*
I certify that is my signature
Date
*
