Blue Sky Moments
INTAKE ASSESSMENT FORM
Participant's Name
*
First Name
Last Name
Participant's Date of Birth
*
-
Month
-
Day
Year
Date
Participant's current age
*
Participant currently lives with (name all family members in the household):
*
Please give a brief history of the participant's background up to now:
*
ex. trauma history, reason in foster care, journey to adoption; anything helpful for Program Director & mentor to know
Participant's strengths and interests:
*
ex. hobbies, favorite school subject, sports, enjoys animals, talents, listens well, people person, etc.
Participant's challenges:
*
ex. physical, mental, emotional; at home, school, etc.
Hopes and Goals for the participant while in the program:
*
What would be an ideal mentor match for the participant?
*
Name of Legal Guardian, DCFS Case Manager, Foster Parent (if applicable):
First Name
Last Name
Participant email (if over 18) or email for Legal Guardian, Case Manager or Foster Parent:
*
example@example.com
Participant Phone Number (if over 18) or phone number for Legal Guardian, Case Manager or Foster Parent:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: