Safe Families for Children



Child Information(Please save this form to your computer and complete it electronically; avoid hand-writing if possible. Thank you!)Child’s Name (Complete one form per child): FORMTEXT ?????Child’s Gender: FORMCHECKBOX F FORMCHECKBOX M Date of Birth: FORMTEXT ????? Age: FORMTEXT ????? Is child receiving other support services? FORMCHECKBOX No FORMCHECKBOX Yes; from? FORMTEXT ?????Caseworker’s Name: FORMCHECKBOX N/A FORMTEXT ????? Phone: FORMTEXT ?????Name of person completing form: FORMTEXT ?????Date: FORMTEXT ?????Family BackgroundFamily members currently in the home: (list) FORMTEXT ?????What is your child’s race/ethnic background? FORMTEXT ?????Primary language spoken in the home? FORMCHECKBOX English FORMCHECKBOX Spanish FORMCHECKBOX French FORMCHECKBOX Other: FORMTEXT ????? Child HealthWas the pregnancy normal? FORMCHECKBOX No FORMCHECKBOX Yes; describe: FORMTEXT ?????Does your child have allergies? FORMCHECKBOX No FORMCHECKBOX Yes; explain: FORMTEXT ?????Is child taking medication? FORMCHECKBOX No FORMCHECKBOX Yes; list: FORMTEXT ?????How is your child’s vision? FORMCHECKBOX Normal FORMCHECKBOX Unknown; describe any problems: FORMTEXT ?????How is your child’s hearing? FORMCHECKBOX Normal FORMCHECKBOX Unknown; describe any problems: FORMTEXT ?????Is child up to date on all immunizations? FORMCHECKBOX No FORMCHECKBOX Yes; explain: FORMTEXT ?????Does your child have any birthmarks or scars? FORMCHECKBOX No FORMCHECKBOX Yes; please describe: FORMTEXT ?????Does your child have a history of any of the following? (Check all that apply): FORMCHECKBOX Hospitalization FORMCHECKBOX Illness FORMCHECKBOX Accident FORMCHECKBOX Injury FORMCHECKBOX Operation FORMCHECKBOX None Describe and include child’s age when event occurred: FORMTEXT ?????When was your child’s last doctor’s appointment? FORMTEXT ?????Is child due for another doctor’s appointment? FORMCHECKBOX No FORMCHECKBOX Yes; when? FORMTEXT ????? (Required) Medical Card Number/Insurance Carrier: FORMTEXT ?????Family Doctor ( FORMCHECKBOX Same as Parent) If same, complete Doctor’s information on Parent Intake Form Doctor’s Name: FORMTEXT ?????Clinic Name: FORMTEXT ?????Address FORMTEXT ????? City FORMTEXT ????? Phone FORMTEXT ?????Child DevelopmentAge when toilet training was complete? FORMTEXT ????? FORMCHECKBOX N/A Does child still wet at night? FORMCHECKBOX No FORMCHECKBOX YesDoes your child have a special word for when he/she uses the toilet? FORMCHECKBOX No FORMCHECKBOX Yes; list: FORMTEXT ?????Does your child have any motor or speech delays? FORMCHECKBOX No FORMCHECKBOX Yes; explain: FORMTEXT ?????What does your child do for fun? FORMTEXT ?????What situations are most difficult/scare your child? FORMTEXT ?????Please list your child’s special abilities: FORMTEXT ?????BehaviorPlease check all that apply to your child:? Overactive FORMCHECKBOX Sexualized Behavior FORMCHECKBOX Easily Distracted FORMCHECKBOX Truant (does not go to school) ? Depressed FORMCHECKBOX Fearful FORMCHECKBOX Steals FORMCHECKBOX Nightmares or Sleep Difficulties FORMCHECKBOX Eating Difficulties FORMCHECKBOX Suicidal FORMCHECKBOX Destroys Property? Depressed FORMCHECKBOX Temper Tantrums FORMCHECKBOX Easily Frustrated FORMCHECKBOX Peer Problems ? Depressed FORMCHECKBOX Hurts him/herself FORMCHECKBOX Touches private parts FORMCHECKBOX Sexual Abuse History ? Depressed FORMCHECKBOX Uses Drugs/Alcohol FORMCHECKBOX Sleep Difficulties FORMCHECKBOX Physical Abuse History FORMCHECKBOX Plays with fire FORMCHECKBOX Wets Bed FORMCHECKBOX Aggressive toward others FORMCHECKBOX School Problems FORMCHECKBOX Withdrawn FORMCHECKBOX Runs Away FORMCHECKBOX Other FORMTEXT ????? Explain any if necessary FORMTEXT ?????Current Behavioral or Academic Problems: FORMTEXT ?????SocialDoes your child have a nickname? FORMCHECKBOX No FORMCHECKBOX Yes; (list): FORMTEXT ?????Child’s favorite friend or relative? FORMTEXT ?????Discipline and training in your home includes: FORMCHECKBOX Timeouts FORMCHECKBOX Explaining Behavior FORMCHECKBOX Spanking FORMCHECKBOX Rewards/Loss of Privileges FORMCHECKBOX Other FORMTEXT ?????How often is discipline needed? FORMTEXT ????? Is discipline effective? FORMCHECKBOX No FORMCHECKBOX YesEducation FORMCHECKBOX N/A School Name: FORMTEXT ????? Phone: FORMTEXT ????? School District: FORMTEXT ?????Teachers Name: FORMTEXT ?????Grade: FORMTEXT ????? Start/End Times: FORMTEXT ?????Does your child have Special Educational needs? FORMCHECKBOX No FORMCHECKBOX Yes; explain: FORMTEXT ?????Would you like help finding services for these needs? FORMCHECKBOX No FORMCHECKBOX YesDaily Habits/Family PracticesChild’s Appetite: FORMCHECKBOX Big FORMCHECKBOX Small FORMCHECKBOX Likes Snacks Favorite foods/drinks? FORMTEXT ?????Food Allergies? FORMCHECKBOX No FORMCHECKBOX Yes; describe: FORMTEXT ?????Is there something your child will not eat/drink? FORMCHECKBOX No FORMCHECKBOX Yes; explain: FORMTEXT ?????Does your child still drink from a bottle? FORMCHECKBOX No FORMCHECKBOX Yes; how often? FORMTEXT ????? Formula brand/type: FORMTEXT ?????Does your child have any skin sensitivities: FORMCHECKBOX No FORMCHECKBOX Yes; explain FORMTEXT ?????Bedtime routine: FORMTEXT ?????Any problems with bedtime? FORMCHECKBOX No FORMCHECKBOX Yes; explain: FORMTEXT ?????Does your child nap? FORMCHECKBOX No FORMCHECKBOX Yes; if Yes, how often and at what times? FORMTEXT ?????Where does child sleep? FORMCHECKBOX Pack-n-Play FORMCHECKBOX Crib FORMCHECKBOX Toddler bed FORMCHECKBOX Big bed FORMCHECKBOX With parent FORMCHECKBOX OtherReligious Affiliation: FORMTEXT ????? Do you attend services? FORMCHECKBOX No FORMCHECKBOX Yes; Location: FORMTEXT ?????Does your child attend daycare? FORMCHECKBOX No FORMCHECKBOX Yes; Where: FORMTEXT ????? Provider name and contact number: FORMTEXT ?????Clothing SizesShirts FORMTEXT ????? Pants FORMTEXT ????? Shoes FORMTEXT ????? Socks FORMTEXT ????? Jackets FORMTEXT ????? Underwear/Diaper Sizes FORMTEXT ????? ................
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