Child Intake Form

Intake Date

YYYY

Name of Person Completing the Application

First Name

Last Name

Case Coordinator

Client Information

Family Name

First Name

Last Name

Client Name

First Name

Last Name

Date of Birth

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Directions to Home

Parent/Legal Guardian Home Phone

(###)

###

####

Parent/Legal Guardian Cell Phone

(###)

###

####

Parent/Legal Guardian Work Phone

(###)

###

####

Community

Tribal Affiliation

Age

Gender

Is there a current CFS case open?

Family History

Mother's Name

First Name

Last Name

Custodial Parent?

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Directions

Phone Number

(###)

###

####

Father's Name

First Name

Last Name

Custodial Parent

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Directions

Phone Number

(###)

###

####

Sibling Information

Please provide the name, age school and address of each sibling

Who provides supervision?

Family Strengths

Have child/children ever received a developmental screening or (school) evaluation before?

If yes. From whom?

if yes. From what?

if yes. When?

Child's Primary Care Provider

Is care covered by IHS, Medicaid, Insurance

Please list all health-related concerns

Please list current family concerns/needs

Total Household Size

Clients Income from All Sources

This includes TANF, Snap, Employment and Unemployment

Clients Comments/Requests

Child Intake Form

Please allow 24-48 hours to respond to your request, if this is an emergency please contact the CFS Hot-line phone at 508-562-9975