Celebrating Families! Family Intake Form
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- Marilynn Carpenter
- 7 years ago
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1 Celebrating Families! Family Intake Form Page can be completed while waiting. Additional comments may be written on the back of page. Intake completed by: Referred by: Today s date: / / Remind participants that in the event there are concerns regarding child safety, you will follow the procedures of the agency which are grounded in your State s child protective laws. Info for Primary Parent/Guardian First name: Last name: Live in home? Yes No Date of birth: / / Address: City: Zip: Home phone: Work phone: Cell phone: Preferred number? Home Work Cell Ethnicity: M/F Parent group: Y/N? Last grade completed in school: First name: Last name: Emergency Contact Relationship: Phone: Address: Second phone: _ City: Zip: Chemical Dependency Family History Who in the family is chemically dependent? Is he/she in a recovery program? How long has he/she been clean and sober? What is his/her support system? Aftercare Twelve Step meetings Counseling How often does he/she attend? _ NOTE: Celebrating Families! is not a treatment program. Individuals in early recovery must regularly attend programs specifically addressing their addiction. Are other family members in recovery? If yes, how long? What is the child(ren) s knowledge of parental substance abuse, domestic violence, and/or incarceration?
2 Information About Child First name: Last name: DOB: / / School: Grade: Behavior or learning problems in school? Health problems? Allergies? Does child have friends? Ethnicity: Preferred language? CF! group assignment: _ Who does child live with? Contact information: Who has legal custody? What is visitation with non-custodial parent? Are there any problematic custody issues or restraining orders that we should know about? Information About Child First name: Last name: DOB: / / School: Grade: Behavior or learning problems in school? Health problems? Allergies? Does child have friends? Ethnicity: Preferred language? CF! group assignment: _ Who does child live with? Contact information: Who has legal custody? What is visitation with non-custodial parent? Are there any problematic custody issues or restraining orders that we should know about?
3 Medical History Mothers Pregnancy Yes No Explain (which child) History Maternal alcohol use Maternal tobacco use Exposure to other toxins (e.g. cocaine, marijuana) Previous miscarriages Previous premature births Caesarean section Violence during pregnancy Length of each pregnancy: 1) wks. 2) wks. 3) wks. Any complications during pregnancies? Birth Weight: 1) lbs. oz. 2) lbs. oz. 3) lbs. oz. Family Information Family History Mother Father Brother(s) Sister(s) Other Relatives Learning difficulties Trouble paying attention Hyperactivity Autism Mental retardation Drug or alcohol abuse Speech problems Mental health concerns Depression Suicide or attempted Domestic violence Violence in the home Other:
4 Have the police ever come to your home? Have children ever been in court? Additional Family Information Has there been violence, abuse or incest in the household/family? If so please describe. Has a report been made? Have there legal problems has the household/family experienced as a result of alcohol and/other drugs? **Please fill out the following section only if the additional parent/guardian is either attending group or shares legal custody of one or more children participating in group. Info for Additional Parent/Guardian First name: Last name: Live in home? Yes No Date of birth: / / Address: City: Zip: Home phone: Work phone: Cell phone: Preferred number? Home Work Cell Ethnicity: M/F Parent group: Y/N? Last grade completed in school: Income level: Family Members Not Participating in Celebrating Families! First name Last name Date of birth: / / M F Lives with: Relationship to child(ren): Which child(ren)? First name Last name Date of birth: / / M F Lives with: Relationship To child(ren): Which child(ren)? Additional people in your current living situation:
5 *I agree to abstain from the use of alcohol or drugs for 24 hours prior to group. *I understand that if I miss more than three classes I will receive a certificate of participation in place of a certificate of completion. Parent Signature Date: / / Policy Regarding Participants Being Under the Influence Celebrating Families! leaders are family advocates. We take our responsibility seriously and make every effort to create a safe and consistent environment for children and families. Anyone arriving under the influence of alcohol or other drugs will be asked to leave, including Session 16 - the Celebration. Children will not be released to drivers who are under the influence. We will contact the emergency number on the children s intake form for an alternative driver. Every effort will be made to get children a safe ride home. It is important for all parents to be aware of this policy. We ask for your active support. Parent/Guardian Signature: Date: Fees (if applicable): Full Payment: Sliding Fee Scale/Other: Person responsible for payment: Name Contact Information: Group Leader Summary and Comments:
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Katherine E. Walker, PhD, LPC, NCC, BCIA-C Licensed Professional Counselor 8300 Health Park, Suite 201 Raleigh, NC 27615 Mobile: 919-760-3068 Fax: 919-676-9946 Email: walker@carolinaperformance.net Couples