Client Intake Form (CHIP)
Complete this intake form if you would like to register a child who has an incarcerated parent.
Child Full Name
First Name
Last Name
Child's Sex
Male
Female
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
What grade is the child currently in? If not in school, highest grade completed.
What school does the child attend?
Child Phone Number If Applicable
Please enter a valid phone number.
Format: (000) 000-0000.
Child Email Address If Applicable
example@example.com
Home Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Full Name
First Name
Last Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Email Address
example@example.com
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Child's Individual Pre-Assessment Info
This section will include information about the child's individual needs.
Is the child experiencing any disciplinary issue in school?
*
Yes
No
Has the child ever been arrested? (If no proceed to next page.)
*
Yes
No
If so, when and for what reason?
Are they still dealing with the legality of the case?
Yes
No
Is the child currently on probation?
Yes
No
If so, please list their Probation Officer’s name & number.
Name
Phone Number
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Incarcerated Parent Info - Please complete all info.
This section will include information about the incarcerated parent.
Full Name
*
First Name
Last Name
Parent's Sex
*
Male
Female
What type of correctional facility is the parent currently in?
*
Federal Prison
State Prison
County Jail
If parent is currently incarcerated in a County jail, have they already been sentenced to prison? (NOTE: A follow-up will be conducted to get necessary information)
*
Yes
No
What is the name of the facility the parent is currently housed in?
*
How long have the parent been incarcerated?
*
When was the last time the child physically seen their parent?
*
When is the last time the child spoke to their parent on the phone?
*
What services would you like to enroll the child in? Select All That Apply
*
Family Bonding Visits with Incarcerated Parent & Child
Access to Educational Pathways (Tutoring, Community Service, Scholarship Assistance, College Tours)
Community Engagement & Outreach (Mental Health, Substance Abuse, Anger Management, Family Bonding)
Positive Development (Mentorship, Financial Literacy, Life Skills, Resume Writing)
When is the parent’s current release date?
*
Does the incarcerated parent have more than one child that need to be enrolled into S.H.I.F.T.I.N.G. Paths? *If so, an additional form will be emailed to you to be completed for each child.
*
Yes
No
By signing below, I agree that I want to receive services from S.H.I.F.T.I.N.G. Paths, Inc. I authorize and give permission to S.H.I.F.T.I.N.G.Paths, Inc. to share information from my submitted application with GovernmentalAgencies, Non-Governmental Organizations, and with Other individuals, only to provide services, resources, and referrals on behalf of my child, or myself. I understand that the information provided will only be shared when necessary to ensure all requirements are met to receive said services.
*
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