Child Intake Form
Tell us about your child and the care you’re requesting. A team member will reach out soon to guide you through the process.
Type of Care Needed
*
Please Select
Long Term Residential Care
Short Term Residential Care
Emergency Residential Care
Respite Care
Parent Support
Child's Full Name
*
First Name
Last Name
Child's Birth Date
*
-
Month
-
Day
Year
Date
Child's Age
*
Child's Gender
*
Please Select
Male
Female
Other
Primary Contact Name
*
First Name
Last Name
Primary Contact Email
*
example@example.com
Primary Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Child
*
Please add social worker, Case worker, probation officer, or judge if applicable.
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Current grade level
*
Name of current (or most recent) enrolled school:
*
Is the child on an IEP (Individual Education Plan)
*
Yes
No
One is being developed
Is the child currently a foster child or under the care of the state?
*
Yes
No
Date of Referral
*
-
Month
-
Day
Year
Date
Does this child have any known allergies?
*
Yes
No
Unknown
List any known allergies (including pet allergies)
Description of the child's medical history:
*
Please use space to list any medical conditions or medications the child takes. Please leave blank if no medical history to add.
Description of the circumstance(s) that led to child's referral:
*
Description of child's current and past behavior:
*
Description of child's social history and school performance.
*
Please list any documents (i.e SSN, medical card, passport, money, immunization record) and valuables that need to be secured or held until discharge. TSFCH is not responsible for locating money or valuables that are not specified on this form.
*
Upload any important documents (IEP, medical history, court notes, medical conditions and instructions, etc)
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Additional Notes or Special Instructions
Signature of Submitter:
*
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