HER.STORY INTAKE FORM
T.P.S.H
Current Name School
Entry Date
/
Month
/
Day
Year
Date
Name
Student ID#
Grade
Date of Birth
/
Month
/
Day
Year
Date
Age
Ethnicity
African American
Asian
White
Hispanic
Other
Primary language spoken:
by student
by parent
Address
Apt #
City
State
Phone
Format: (000) 000-0000.
Parent/Guardian
Parent/Guardian: Home
Work/Cell Phone
Format: (000) 000-0000.
Emergency Contact
Relationship
Phone
Format: (000) 000-0000.
Phone/Fax
Format: (000) 000-0000.
Due Date
/
Month
/
Day
Year
Date
Last Menstrual Period (LMP)
Date of first prenatal visit
/
Month
/
Day
Year
Date
Date of Next OB/GYN appointment
/
Month
/
Day
Year
Date
Plans for Child
Keep Child
Adoption
Previous pregnancies
Yes
No
If yes, please list name of child, date of birth, & birth weight.
INTAKE FORM
Name of the Father of the Baby
Age
Parents, legal guardians, or caregivers if you checked this box, check one or both of the boxes below, if
In my own home or apartment, in Section 8 housing, HUD Subsidized Housing or in military housing with
My home has no electricity
My home has no running water
Living in a shelter
Living in a motel or hotel
Living with more than one family in a house or
Moving from place to place
Living in a structure not usually used for housing
Living in a car, park,
Other
UNACCOMPANIED YOUTH (An unaccompanied youth is a student who is not in the physicalcustody of a parent or legal guardian. This would include students living with non-custodial relatives or friends without a parent or legal guardian.)
Yes
No
Check if receiving any of these services
WIC
Medicaid/CHIPs
Free/Reduced Lunch
Food Stamps
Social Security/Disability
Case Management
NCI/Day Care Assistance
Other
INTAKE FORM
NEEDED SERVICES
NCI Enrollment Assistance
Free Lunch/Breakfast (Child Nutrition)
Immunizations
Temporary Assistance for Needy Families (TANF)
If other services are needed please list below:
Temporary Assistance for Needy Families (TANF)
Emergency Clothing, Uniforms
Personal Hygiene Items
Food Stamps (SNAP) Assistance
Transportation
School Supplies
Medicaid/CHIP Assistance
Please provide an introduction of who you are, your day to day life, your past, and your future dreams for you and your child. (Minimum 5-10 sentences)
Submit one of your favorite pictures below.
To the best of my knowledge this information is true and correct.
Name (PLEASE PRINT)
Signature
Preview PDF
Submit
Should be Empty: