OUTREACH
HARRIS COUNTY YOUTH INTERVENTION FORM
Profile of Child or (Children)
Today's Date
/
Month
/
Day
Year
Date
Child's Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Currently Attending:
Grade:
Please Select
1st
2nd
3rd
4th
5th
6th
7th
8th
Freshman
Sophomore
Junior
Senior
Known Conditions or Disabilities:
Gender
Please Select
Male
Female
Other
Race
Please Select
White
African-American
Hispanic
Asian
American Indian
Child Resides with:
Please Select
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Adults Residing with Child
Adult #1
First Name
Last Name
Phone Number
Employment:
Relationship to Child:
Please Select
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Adult #1 Email
Speaks English:
Yes
No
Adult #2
First Name
Last Name
Phone Number
Employment:
Relationship to Child:
Please Select
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Adult #2 Email
example@example.com
Speaks English:
Yes
No
Do Others Reside with Child:
Please Select
Yes
No
Others Residing with Child
Name
First Name
Last Name
Relationship to Child:
Please Select
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Name
First Name
Last Name
Relationship to Child:
Please Select
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Name
First Name
Last Name
Relationship to Child:
Please Select
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Other NOT Residing with Child:
Please Select
Yes
No
Other NOT Residing with Child
Adult #1
First Name
Last Name
Phone Number
Employment:
Relationship to Child:
Please Select
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Other Email
example@example.com
Speaks English:
Yes
No
Adult #2
First Name
Last Name
Phone Number
Employment:
Relationship to Child:
Please Select
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Other #2 Email
example@example.com
Speaks English:
Yes
No
Incident Information
Date of Incident
-
Month
-
Day
Year
Date
Incident Case#
Time of Incident
Hour Minutes
AM
PM
AM/PM Option
Address where Incident Occured
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Multiple Juveniles
Please Select
Yes
No
Names of Other Juveniles
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Ignition Source:
Intentional?
Please Select
Yes
No
Accelarant Used:
Injuries
Please Select
Yes
No
Describe Injury
Hospitalization:
Please Select
Yes
No
Death(s)
Please Select
Yes
No
Location of Fire:
Please Select
Residential Home
Building
Other
Type of Area
Please Select
Living Room
Kitchen
Restroom
Bedroom
Garage
Hallway
Inside of Structure
Please Select
Yes
No
Outside of Structure:
Please Select
Yes
No
Items Set on Fire:
Estimated Damage:
Supervised by Someone over 12:
Please Select
Yes
No
Occupied at Time of Fire:
Please Select
Yes
No
Caregiver Smokes
Please Select
Yes
No
Unknown
Smoke Detector in Home:
Please Select
Yes
No
Unknown
Charges Filed:
Please Select
Yes
No
Pending
Type of Charges:
Describe Incident:
Referral Information
Referred by:
First Name
Last Name
Agency:
Work Phone:
Cell Phone
Referred by Email
example@example.com
Notes:
Attachments
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