Futures Unwalled

FUTURES UNWALLED

BREAKING BARRIERS & BUILDING FUTURES
Mail: 16787 Beach Blvd., #1005, Huntington Beach, CA 92647

Phone: 714-253-4060

Email: connect@futuresunwalled.org
Intake Form
Contact & Household Information
Parent/Guardian Full Name

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent Email Address
example@example.com
Parent Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Contact Method
Preferred Contact Method - Other (please specify)
Best Days/Times to Reach You
Relationship to Child
Student's Information & School Details
Child's Full Name

First NameLast Name
Childs Age
Student's Date of Birth

MonthDayYear
Date
Child's Gender

Other
Grade Level
School
District
What services does your child receive outside of school?
What services does your child receive at school?
Is your child a Regional Center client?

Other
Family & Background Information

This helps us understand who we are serving and improve access to support. You can skip any question.
What is your child’s race/ethnicity? (Select all that apply)

Other
What is the primary language spoken at home?
Is an interpreter needed
What type of health insurance does your child have? (Check all that apply)
What is your current housing situation?
How many children are in you household?
How many adults are in your household?
What is your household’s approximate annual income?
Support Needs and Concerns
Primary reason for seeking support (choose all that apply)

Other
Primary reason for seeking support - Other (please specify)
Does your child have an IEP or 504 Plan?
Describe your main concerns or goals for your child
Please describe your concerns or what you're hoping to receive help with
Diagnosis or areas of concern
What’s the most urgent issue you need help with right now?
Support Areas Survey
What challenges does the child face that you have noticed (Check all that apply)

Other
Please share more about the barriers the child is facing right
Is there anything else impacting the child that we should know?
Referral, Consent, File Submission, and Notes
How did you hear about Futures Unwalled?
Consent to Contact
Confidentiality Notice
Upload Documents (Optional)

Cancelof
Notes
Signature
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Intake Form

Contact & Household Information

Student's Information & School Details

Family & Background Information

Support Needs and Concerns

Support Areas Survey

Referral, Consent, File Submission, and Notes