Circle of Friends
Youth Demographics - Intake Form
Youth's First Name
Middle Int.
Youth's Last Name
Date of Birth
-
Month
-
Day
Year
Date
Youth identifies as:
Female
Male
Other
Address
Street/Mailing Address
Street Address Line 2
City
State
Zip
Parent/Guardian #1 Full Name
Parent/Guardian #1 Cell Phone
Parent/Guardian #1 E Mail
example@example.com
Parent/Guardian #1 relationship to youth
Parent/Guardian #2 Full Name
Parent/Guardian #2 Cell Phone
Parent/Guardian #2 E Mail
example@example.com
Parent/Guardian #2 relationship to youth
Who does this youth live with:
Both biological parents
Biological mother
Biological father
Biological parent and stepparent
Biological parent and adoptive parent
Adoptive parent(s)
Grandparent(s)
Other relative(s)
Foster Parent(s)
Is this person(s) the youth's legal guardian?
Yes
No
Don't Know
Total number of adults or other adult relatives in the household:
1
2
3
4 or more
Total number of siblings or other children int the household:
0
1
2
3
4
5
6
7 or more
Is there anyone youth SHOULD NOT be allowed to visit or have contact with?
Yes
No
If YES, please list
Is there legal documentation to support this? (If Yes, please provide a copy to CoF)
Yes
No
Current School
Current Grade
Please Select
Pre-K
K
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Current Teacher
Does the youth receive FREE and/or REDUCED lunch?
Yes
No
Don't Know
Ethnicity:
Hispanic
Non-Hispanic
Don't Know
Primary Language
English
Spanish
Chinese
Other
Other languages spoken at home:
Does the youth speak English as a second or other language?
Yes
No
Race: (If youth identifies as two or more races, please check all that apply)
Asian
Latino
Pacific Islander
Black
Indigenous
White
Other
Decline to Answer
Youth has experienced houselesness:
Yes
No
Don't Know
Youth currently has OR has had an incarcerated parent:
Yes
No
Don't Know
Youth OR family has had interaction with the justice system:
Yes
No
Don't Know
Youth has a family member who identifies as LGBTQ+:
Yes
No
Don't Know
Youth OR family member has an ADA Disability:
Yes
No
Don't Know
Parent/Guardian Signature
Today's Date
/
Month
/
Day
Year
Date
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Should be Empty: