IB Intake Form

Name

First NameLast Name

Email

example@example.com

1). What is safe sex?

2). Do you have access to contraceptives?

3). Do you know how to properly use contraceptives?

4). What is an S.T.D. (sexually transmitted disease)?

5 Do you know what steps to take if you think you have contracted an S.T.D.?

6). What is good personal hygiene?

7). How often should you bath?

8). Have you been shown proper hygiene methods?

9). The genital area needs a special cleaning method? True or False

10). Do you visit the dentist twice a year?

11). How is a tattoo applied to the skin?

12). How long does it take a tattoo to heal?

13). What health problems may be associated with getting a tattoo or piercing?

14). What problems can develop from body piercings?

15). Besides cleanliness and hygiene what else should a tattoo/piercing shop offer?

15). What is effective communication?

15). What is ineffective communication?

16). How important is listening in communication?

17). Is your tone important when communicating?

18). Is your body language a form of communication?

19). What is a gang?

20). Have you ever been affiliated with a gang?

21). What are some consequences of being associated with a gang?

22). What would make a person join a gang?

23). What is the purpose of a gang?

24). What is the purpose of a gang?

25). Why is education important?

26). Are you currently enrolled in school?

27 Do you feel comfortable talking to your teachers if you are having difficulties?

28). How do you plan to further your education past High School?

29). Do you have a library card?

30). What are your top 3 educational goals?

31). What are 3 coping skills you use when you are angry?

32). Do you have violent outburst?

33). Have you harmed yourself or others due to your anger?

34). Can you tell when you are stressed out?

35). What triggers your anger?

I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND ISIGN OF MY OWN FREE WILL.

(Child's Name)

(Parent/Guardian's Signature)

(Parent/Guardian's Printed Name)

(Date)

Date

(Parent Phone)