Family Intake Record

Family Intake Record

Page 1
Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
FemaleMaleSelf Describe
Street Address
City
County
Zip Code
Phone Number:*
Format: (000) 000-0000.
Email Address:*
example@example.com
SingleMarriedNot married but living with partnerSeparatedWidowedDivorced

List Children currently living with you:*

Rows	Full Name	Gender	Age & Date of Birth
1
2
3
4
5
6

Do you have any children that are not currently living in your household? If yes, please list them below:*

List other adults, not including you, living in your household:*

Rows	Full Name	Gender	Age & Date of Birth	Relationship to you
1
2
3

Family Intake Record

Page 3
Contact and Communication Instructions and Consent

I agree to allow GPYFS Staff to contact me using the following methods regarding any services provided. I authorize/do not authorize GPYFS staff to leave messages for me when I am unavailable as indicated below.
What is your primary language?*
Secondary language?
Phone CallText MessageEmailFace to Face
NoYes
Additional communication instructions:
Signature*

Family Intake Record

Page 4
Consent for Services
I, the undersigned, give my consent for the services that I am requesting from Great Plains Youth & Family Services, Inc. I understand that the risks and benefits for these services will be explained to me and that I will have the opportunity to ask questions. I also understand that:
- The information regarding myself and my family/household that I provided may be entered into GPYFS, Inc. information systems to be used for program evaluations, management, and billing purposes.
- I will not be denied service because of inability to pay.
- I may refuse service at any time.
Limit of services:

GPYFS employees are not phycologists or medical professionals. We do not diagnose developmental, psychological, or medical conditions. However, we can help connect you to qualified professionals and resources to assist.

Confidentiality:

GPYFS, Inc. will not release confidential information without your written permission with the following exceptions:
- Our program may share information without your consent in order to protect you or others from serious harm (for example, if a family member plans to harm themselves, if a family member plans to harm another person, or if there are concerns about abuse or neglect of a child or elderly person).
- Our program may release information if we receive a court order requiring us to do so.
Photographs, and Other Media:

I/We give our consent for photographs or other media of taken while at GPYFS or at any GPYFS programming to be used in newsletters, displays, websites, newspapers, or other public relation venues.
I have read and understand the above and agree to participate in GPYFS Family Resource Center services.
Signature*

Family Intake Record

Page 5
GPYFS FRC Behavior Policy & Strike System
Purpose:

To ensure a safe, respectful, and supportive environment for all families and staff, the Family Resource Center has implemented a behavior policy and strike system. This policy outlines expectations and consequences for inappropriate behavior.

Behaviorial Expecations:

All families and individuals accessing services at the Family Resource Center are expected to:
- Treat staff and other families with respect at all times.
- Refrain from demanding items or services in a disrespectful or aggressive manner.
- Avoid any physical contact with staff, especially inappropriate touching or physical aggression.
- Communicate needs and concerns calmly and respectfully.
- Not attempt to "double dip" by accessing the same products or services from the Family Resource Center at both Hobart and Altus.
Strike System

Upon intake, all families must sign this document acknowledging their understanding and agreement to the behavior policy.
- Strike 1:
  If a family member violates the behavior policy, they will receive a written strike. This will be documented and discussed with the individual involved.
- Strike 2:
  If a second violation occurs, the individual or family will be permanently banned from accessing the Family Resource Center.
Immediate Ban Clause:

Staff reserve the right to immediately ban any individual or family without prior strikes if the behavior poses a safety risk to staff, other families, or the individual themselves. This includes but is not limited to:
- Physical attacks or threats
- Sexual harassment or inappropriate touching
- Severe verbal abuse or intimidation
Acknowledgement:

By signing below, I acknowledge that I have read, understood, and agree to abide by the GPYFS Family Resource Center's behavior policy and strike system.
Signature*
Should be Empty:

Family Intake Record

Family Intake Record

Family Intake Record

Consent for Services

Family Intake Record

GPYFS FRC Behavior Policy & Strike System