Client Intake Form
Project Family First
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child(red) data - Please enter each Child's Name, Age, and Race. Example: Jane Doe, 5, BlackR
*
If your child(ren) has been removed, what is the date of the next court hearing
Briefly describe the reason(s) for DHS Child Welfare involvement
If you believe you are not being treated fairly by DHS, please describe.
Briefly describe your ideal resolution to this issue
How can we best support you at this time? (choose all that apply)
Advocacy During CPS Investigation
Court Attendance
Family Decision Meeting Attendance
Case Plan Review
Referral to Culturally Informed Resources
Relative/Kinship Placement Advocacy
Visitation Advocacy
Current Phase (choose one)
CPS Investigation
Open Child Welfare Case - Child in home
Child in the Cusotdy of the Statef - Placed with Strangers
Child in the Cusotdy of the Statef - Placed with Relatives or Friends of the Family
Caseworker Information: Name, Phone, Email, County
Mother's Attorney Info: Name, Phone, Email
Father's Attorney Info: Name, Phone, Email
Submit
Should be Empty: