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Child Intake Form (1 of 2)

Child intake Form (1 of 2)
Whom may we thank for referring you?
Name
Family Information
Name, DOB, Relationship(full/half sib., foster, biological, adopted) CURRENTLY LIVING (in home, away at school, with another family, etc.)
Name, DOB, Relationship(full/half sib., foster, biological, adopted) CURRENTLY LIVING (in home, away at school, with another family, etc.)
Name, DOB, Relationship(full/half sib., foster, biological, adopted) CURRENTLY LIVING (in home, away at school, with another family, etc.)
Name, DOB, Relationship(full/half sib., foster, biological, adopted) CURRENTLY LIVING (in home, away at school, with another family, etc.)
Name, DOB, Relationship(full/half sib., foster, biological, adopted) CURRENTLY LIVING (in home, away at school, with another family, etc.)
Name, DOB, Relationship(full/half sib., foster, biological, adopted) CURRENTLY LIVING (in home, away at school, with another family, etc.)
Name, DOB, Relationship(full/half sib., foster, biological, adopted) CURRENTLY LIVING (in home, away at school, with another family, etc.)
Information about others living in the home:
Name, Age, Gender, Relationship to child
Name, Age, Gender, Relationship to child
Name, Age, Gender, Relationship to child
Name, Age, Gender, Relationship to child
Name, Age, Gender, Relationship to child
Name, Age, Gender, Relationship to child
Name, Age, Gender, Relationship to child
Name, Age, Gender, Relationship to child
How would you describe your child’s physical appearance? (e.g. height, weight, eye and hair color, distinguishing characteristics, manner of dress):
With whom has child lived in the past?
DATES, TYPE OF PLACEMENT*, NAMES OF CAREGIVERS, REASON FOR MOVE
DATES, TYPE OF PLACEMENT*, NAMES OF CAREGIVERS, REASON FOR MOVE
DATES, TYPE OF PLACEMENT*, NAMES OF CAREGIVERS, REASON FOR MOVE
DATES, TYPE OF PLACEMENT*, NAMES OF CAREGIVERS, REASON FOR MOVE
DATES, TYPE OF PLACEMENT*, NAMES OF CAREGIVERS, REASON FOR MOVE
DATES, TYPE OF PLACEMENT*, NAMES OF CAREGIVERS, REASON FOR MOVE
DATES, TYPE OF PLACEMENT*, NAMES OF CAREGIVERS, REASON FOR MOVE
DATES, TYPE OF PLACEMENT*, NAMES OF CAREGIVERS, REASON FOR MOVE

*TYPE OF PLACEMENT: Birthparent(s), birth relative(s), foster parent(s), adoptive parent(s), step parent(s), group home, institution, residential treatment center, other.

PLEASE DESCRIBE CHILD’S BIRTH AND DEVELOPMENTAL HISTORY, IF KNOWN:
Age of birthmother at time of child’s birth
Birthmother’s total number of pregnancies
(this child was pregnancy #)
Miscarriages
Abortions
Problems during pregnancy with this child:
Unusual weight gain (if yes, how much? )
Unusual weight loss (if yes, how much? )
Medicines taken during pregnancy (please list names and reasons for taking):
Disease or exposure to contagious disease (please explain):
Persistent emotional stress, depression, or anxiety (please explain):
Premature?

Please Complete the second half of the Child Intake Form