OUTREACH
HARRIS COUNTY YOUTH INTERVENTION FORM
Profile of Child or (Children)
Date Received by
/
Month
/
Day
Year
Date
Child's Name
First Name
Last Name
Date of Birth
/
Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Currently Attending:
Grade:
1st
2nd
3rd
4th
5th
6th
7th
8th
Freshman
Sophomore
Junior
Senior
Known Conditions or Disabilities:
Gender
Male
Female
Other
Race
White
African-American
Hispanic
Asian
American Indian
Child Resides with:
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Adults Residing with Child
Adult #1
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Employment:
Relationship to Child:
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Email
example@example.com
Speaks English:
Yes
No
Adult #2
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Employment:
Relationship to Child:
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Email
example@example.com
Speaks English:
Yes
No
Do Others Reside with Child:
Yes
No
Others Residing with Child
Name
First Name
Last Name
Relationship to Child:
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Name
First Name
Last Name
Relationship to Child:
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Name
First Name
Last Name
Relationship to Child:
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Other NOT Residing with Child:
Yes
No
Other NOT Residing with Child
Adult #1
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Employment:
Relationship to Child:
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Email
example@example.com
Speaks English:
Yes
No
Adult #2
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Employment:
Relationship to Child:
Father
Mother
Grandfather
Grandmother
Step Father
Step Mother
Brother
Sister
Uncle
Aunt
Other
Email
example@example.com
Speaks English:
Yes
No
Incident Information
Date:
-
Month
-
Day
Year
Date
Incident Case#
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Multiple Juveniles
Yes
No
Names of Other Juveniles
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Name
First Name
Last Name
Ignition Source:
Intentional?
Yes
No
Accelarant Used:
Injuries
Yes
No
Describe Injury
Hospitalization:
Yes
No
Death(s)
Yes
No
Location of Fire:
Residential Home
Building
Other
Type of Area
Living Room
Kitchen
Restroom
Bedroom
Garage
Hallway
Inside of Structure
Yes
No
Outside of Structure:
Yes
No
Items Set on Fire:
Estimated Damage:
Supervised by Someone over 12:
Yes
No
Occupied at Time of Fire:
Yes
No
Caregiver Smokes
Yes
No
Unknown
Smoke Detector in Home:
Yes
No
Unknown
Charges Filed:
Yes
No
Pending
Type of Charges:
Describe Incident:
Referral Information
Referred by:
First Name
Last Name
Agency:
Work Phone:
-
Area Code
Phone Number
Cell Phone
-
Area Code
Phone Number
Email
example@example.com
Notes:
Attachments
Browse Files
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of
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hcfmo.net
or call 713-274-1700
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