CHINS Intake Form
Date
/
Month
/
Day
Year
Date
Attorney (Office use only)
ZMP
EMC
Do both parents reside together?
Yes
No
You are
Mother
Father
Grandparent or Other Third Party
Name
Address
City
State
ZIP
County of Residence
Phone Numbers: Cell
Format: (000) 000-0000.
Work
Other
Email Address
example@example.com
Date of Birth
/
Month
/
Day
Year
Date
Social Security Number
Employer
Employer Address
Average Weekly Income
Paid
Hourly
Salary
Mother's
Information
(If not listed above)
Name
Address
City
State
ZIP
County of Residence
Phone Numbers: Cell
Format: (000) 000-0000.
Work
Other
Date of Birth
/
Month
/
Day
Year
Date
Social Security Number
Employer
Employer’s Address
Employer’s Address
Average Weekly Income
Paid
Hourly
Salary
Father's
I
nformation
(
I
f not listed above)
Name
Address
City
State
ZIP
County of Residence
Phone Numbers: Cell
Format: (000) 000-0000.
Work
Other
Date of Birth
/
Month
/
Day
Year
Date
Social Security Number
Employer
Employer’s Address
Employer’s Address
Average Weekly Income
Paid
Hourly
Salary
Children
Rows
Name
Date of Birth
SSN
Gender
Highest Education Level
Child 1
Child 2
Child 3
Child 4
Which parent has custody of the children?
Mother
Father
Both
In what County and State do the children currently reside?
Have they resided in their current state and county for the preceding six months?
No
Yes
If No, in what County and State did they previously reside?
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