Child Intake Form


	Date:

[___/___/___]


	Time:

[____:____]


	New


	Reopened

CHILD INFORMATION

CAREGIVER INFORMATION

First Name:


	Last Name:

P. O. Box/Village:


	Home or Work Ph:


	Date of Birth:

SSN:

Place of Birth:


	Gender:


	Male

	Female


	Am. Samoa

	Samoa

	Fiji

		Phillipino


	China/Korea


		Tonga

	USA


	Other


	Citizenship:


	Race:


	Ethnicity:


	Employer:


	Ed Level:


	Marital Status:


	Single


	Married


	First Name:


	Last Name:


	P. O. Box/Village:


	Home or Work Ph:


	Date of Birth:


	SSN:


	Gender:


	Place of Birth:


		Am. Samoa

		Samoa

		Fiji

	Phillipino


	Male

		Female


	China/Korea


		Tonga

		Fiji

	Other


	Citizenship:


	Race:

		Ethnicity:


	Employer:


	Ed Level:

		Divorced


	Widowed


	Common Law

HOUSEHOLD INFORMATION

	Name	Gender	Age	Relationship

SUPPLEMENTAL INCOME INFORMATION

PROBLEM/REFERRAL INFORMATION

Social Sec. Income:


	Retirement or Pension:

Child Support:

Total Household Income:

WIC/A SNAP?:

VA BENEFITS?:


	Yes

		Yes


	No

		No


	Primary Presenting Problem:

		Secondary Presenting Problem:

			Tertiary Presenting Problem:

				Referral Person:

table-a102


	Referred From:


	DOE SPED

		DOE School

		DOE Drug Free


	DPSS

	Juvenile/TCF

	Court


Referred To:

	Date:


	DOE SPED

		LBJ ER

		LBJ SS

		LBJ MHC


	Shelter

		Self

				Family Mbr.

			Church/Faithbs


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