Intake Form

Date*

Submitted By:*

Previously Hosted?

Guardian/Caller Information

Name*

First Last

Phone

Email

Date of Birth

Referred By:

Emergency Contact Person

First Last

Emergency Contact Phone Number

Relationship

Where are you and the kids living right now (address/City)?

Street Address City State / Province / Region ZIP / Postal Code

Bio Parent Information

What is the current crisis that is preventing or hindering the parent/guardian from providing care for their children? "Tell me why you called today?" or "What is going on that you need our help?" * Previously Hosted Families - Has there been any major life changes that have happened since the last time we hosted your children?

What is the estimated length of placement needed? Explain SR 2 week & 30 day re-evaluation requirement. How many children do you have who need to be hosted? How much support are you looking for? How long do you need us to host? Are there any specific days (start-end hosting)?

When do you need placement by?

Do you have legal custody of the children? If not who else does? Would they be willing to sign the Placement Paperwork? Will they object to you signing the Custodial Agreement?

Are you currently struggling with any substance abuse issues? *If YES what are they using now and are they in treatment? Have you in the past? What was your primary choice? Moms - When you were pregnant did you use?

Has there ever been CPS/CWS involvement with any of your children before? Can you share what happened?

The following question is just a question to track. Our non-profit is trying to prevent children from entering the foster care system. Growing up, did you spend time in foster care? Do you remember how long, what was your experience like? Ask with care and compassion.

Are you currently seeking or have been under physician care for mental health support? Are there any mental wellness issues we need to be aware of?

Have you ever been a victim of a violent crime?

What kind of transportation do you use? (own car or public transportation)

What is your source of income?

What Community Resources are you using or have you used? (Check if they are working with a Case Manager from a partnering agency)

Goals - *Aim for the goal(s) to be TIED TO THE CRISIS. Guide caller to think about how they can use their own talents and capabilities and what is available to them to bring their family out of crisis and towards stability. Check for goals possibly set with Case Manager from Partnering Agency.

Let’s talk about some goals. What is your plan to improve your situation while your children are in our program?

Children to Be Hosted

How many children do you need hosted?

Child #1: Name

First Last Suffix

Child #1: Date of Birth

Child #1: Age

Child #1: Gender

Child #1: Name of School or Daycare (Grade and City) Is Daycare available for Host Family to use?

Child #1: School and City?

Child #1: Is there an IEP in place?

Child #1: Tell me a little about your child's personality?

Child #1: What makes him/her happy? What kinds of things does your child like to do?

Child #1: What comforts him/her?

Child #1: How does he/she play with other children? How about with siblings or younger or older children? Is your child’s behavior around other children aggressive in any way? Does your child have any problems in school?

Is there anyone in your child's like that has served jail time? Is there anyone in your child's like who is violent? Is there anyone in your child's life who has substance abuse issues?

Child 1: How is your relationship with this child’s mom/dad? (other parent) Is there a restraining order? Is there anyone else who shouldbe able to visit your child? (should there be a need) Is there anyone who should NOT VISIT with your child?

Has child #1 ever witnessed Domestic Violence? Has your child been a victim of physical or sexual abuse that you are aware of?

What is child #1's daily schedule?

Child #1: What is your child's bedtime routine? Does your child have sleeping problems? Where does this child currently sleep? Co-sleeper with a parent? Does your child have bed wetting problems? Does the child wear a diaper or pull up to bed?

Has child #1 ever been separated from his/her parents before? *Who were they with, was it someone they knew? How did he/she do?

Does child #1 have any food needs or allergies we need to be aware of? Food Likes? Food Dislikes?

Is child #1 allergic to any animals? Does he/she have a fear of animals?

Child 1: What type of Medical Insurance? State/County Health Coverage or Private: Do you have your child’s Medical ID card? *Explain that a picture will be taken of their child’s Medical ID Card or Social Security Card is needed to move forward.

Is child #1 up-to-date on immunizations? If not, can we help get the child to a doctor?

Does your child #1 have any MEDICAL NEEDS OR SPECIAL NEEDS we need to be aware of? Does your child have any ALLERGIES?

Is your child #1 taking any prescription MEDICATIONS? If yes what kind? What time is medication taken? Please provide clear instructions. Any medications MUST be in original prescription bottles!

Child #1 Doctor? City?

Check For: Formula Type? Diapers/Pull Ups Size? Do they have a car seat to provide at Hosting Launch? They can pack anything that will help the child to be comfortable (blanket, binky, special teddy bear.)

Is there anything else that you would like to tell us about your child?

Child #2: Name

First Last Suffix

Child #2: Date of Birth

Child #2: Age

Child #2: Gender

Child #2: Name of School or Daycare (Grade, Is daycare available for Host Family to use?)

Child #2: School and City?

Child #2: Is there an IEP in place?

Child #2: Tell me a little about your child's personality?

Child #2: What makes him/her happy? What kinds of things does your child like to do?

Child #2: What comforts him/her?

Child #2: How does he/she play with other children? How about with siblings or younger or older children? Is your child’s behavior around other children aggressive in any way? Does your child have any problems in school?

Child 2: How is your relationship with this child’s mom/dad? (other parent) Is there a restraining order? Is there anyone else who shouldbe able to visit your child? (should there be a need) Is there anyone who should NOT VISIT with your child?

Has child #2 ever witnessed Domestic Violence? Has your child been a victim of physical or sexual abuse that you are aware of?

What is child #2's daily schedule?

Child #2: What is your child's bedtime routine? Does your child have sleeping problems? Where does this child currently sleep? Co-sleeper with a parent? Does your child have bed wetting problems? Does the child wear a diaper or pull up to bed?

Has child #2 ever been separated from his/her parents before? *Who were they with, was it someone they knew? How did he/she do?

Does child #2 have any food needs or ALLERGIES we need to be aware of? Food Likes? Food Dislikes?

Is child #2 allergic to any animals? Does he/she have a fear of animals?

Child 2: What type of Medical Insurance? State/County Health Coverage or Private: Do you have your child’s Medical ID card? *Explain that a picture will be taken of their child’s Medical ID Card or Social Security Card is needed to move forward.

Is child #2 up-to-date on immunizations? If not, can we help get the child to a doctor?

Does child #2 have any MEDICAL NEEDS OR SPECIAL NEEDS we need to be aware of? Does you child have any type of ALLERGIES?

Is child #2 taking any prescription MEDICATIONS? If yes what kind? What time is medication taken? Please provide clear instructions. Any medications MUST to be in original prescription bottles!

Child #2 Doctor? City?

Check For: Formula Type? Diapers/Pull Ups Size? Do they have a car seat to provide at Hosting Launch? They can pack anything that will help the child to be comfortable (blanket, binky, special teddy bear.)

Is there anything else that you would like to tell us about your child?

Child #3: Name

First Last Suffix

Child #3: Date of Birth

Child #3: Age

Child #3: Gender

Child #3: Name of School or Daycare (grade, Is daycare available for Host Family to use?)

Child #3: School and City?

Child #3: Is there an IEP in place?

Child #3: Tell me a little about your child's personality?

Child #3: What makes him/her happy? What kinds of things does your child like to do?

Child #3: What comforts him/her?

Child #3: How does he/she play with other children? How about with siblings or younger or older children? Is your child’s behavior around other children aggressive in any way? Does your child have any problems in school?

Child 3: How is your relationship with this child’s mom/dad? (other parent) Is there a restraining order? Is there anyone else who shouldbe able to visit your child? (should there be a need) Is there anyone who should NOT VISIT with your child?

Has child #3 ever witnessed Domestic Violence? Has your child been a victim of physical or sexual abuse that you are aware of?

What is child #3's daily schedule?

Child #3: What is your child's bedtime routine? Does your child have sleeping problems? Where does this child currently sleep? Co-sleeper with a parent? Does your child have bed wetting problems? Does the child wear a diaper or pull up to bed?

Has child #3 ever been separated from his/her parents before? *Who were they with, was it someone they knew? How did he/she do?

Does child #3 have any food needs or allergies we need to be aware of? Food Likes? Food Dislikes?

Is child #3 allergic to any animals? Does he/she have a fear of animals?

Child 3: What type of Medical Insurance? State/County Health Coverage or Private: Do you have your child’s Medical ID card? *Explain that a picture will be taken of their child’s Medical ID Card or Social Security Card is needed to move forward.

Is child #3 up-to-date on immunizations? If not, can we help get the child to a doctor?

Does child #3 have any MEDICAL NEEDS OR SPECIAL NEEDS we need to be aware of? Does your child have any type of ALLERGIES?

Is child #3 taking any prescription MEDICATIONS? If yes what kind? What time is medication taken? Please provide clear instructions. Any medications MUST be in original prescription bottles!

Check For: Formula Type? Diapers/Pull Ups Size? Do they have a car seat to provide at Hosting Launch? They can pack anything that will help the child to be comfortable (blanket, binky, special teddy bear.)

Child #3 Doctor? City?

Is there anything else that you would like to tell us about your child?

Child #4: Name

First Last Suffix

Child #4: Date of Birth

Child #4: Age

Child #4: Gender

Child #4: Grade in School

Child #4: Name of School or Daycare (grade, Is daycare available to Host Family?)

Child #4: Is there an IEP in place?

Child #4: Tell me a little about your child's personality?

Child #4: What makes him/her happy? What kinds of things does your child like to do?

Child #4: What comforts him/her?

Child #4: How does he/she play with other children? How about with siblings or younger or older children? Is your child’s behavior around other children aggressive in any way? Does your child have any problems in school?

Child 4: How is your relationship with this child’s mom/dad? (other parent) Is there a restraining order? Is there anyone else who shouldbe able to visit your child? (should there be a need) Is there anyone who should NOT VISIT with your child?

Has child #4 ever witnessed Domestic Violence? Has your child been a victim of physical or sexual abuse that you are aware of?

What is child #4's daily schedule?

Child #4:What is your child's bedtime routine? Does your child have sleeping problems? Where does this child currently sleep? Co-sleeper with a parent? Does your child have bed wetting problems? Does the child wear a diaper or pull up to bed?

Has child #4 ever been separated from his/her parents before? *Who were they with, was it someone they knew? How did he/she do?

Does child #4 have any food needs or allergies we need to be aware of? Food Likes? Food Dislikes?

Is child #4 allergic to any animals? Does he/she have a fear of animals?

Child 4: What type of Medical Insurance? State/County Health Coverage or Private: Do you have your child’s Medical ID card? *Explain that a picture will be taken of their child’s Medical ID Card or Social Security Card is needed to move forward.

Is child #4 up-to-date on immunizations? If not, can we help get the child to a doctor?

Does child #4 have any MEDICAL NEEDS OR SPECIAL NEEDS we need to be aware of?

Is child #4 taking any prescription MEDICATIONS? If yes what kind? What time is medication taken? Please provide clear instructions. Any medications MUST be in original prescription bottles!

Child #4 Doctor? City?

Check For: Formula Type? Diapers/Pull Ups Size? Do they have a car seat to provide at Hosting Launch? They can pack anything that will help the child to be comfortable (blanket, binky, special teddy bear.)

Is there anything else that you would like to tell us about your child?

Other Information to Communicate

If the family has been homeless, living in shelters, is there a concern over lice? Has there been any problems with lice? Ask with Care and Compassion.

Do you prefer your children to be placed in a home together or in different homes?

Are you ok with the following?

• If children are placed with SRFC host family, there is an expectation that you will be in contact with your children DAILY (each night) through host family.

• For any child over 12, SRFC staff needs to speak with them to assess their willingness to participate in the program so that parent can get the help needed.

• SRFC is a faith-based organization. We encourage our host families to include the children they are hosting in all their daily activities; this could include church on Sundays. Are you OK with that?

Reminder - Please bring your ID, medical IDs for each child, car seats (if they have them) any medications MUST be in prescription bottles, anything else you think your child(ren)will need during the host.

Providing safe and healthy homes for children of families in crisis.

Guardian/Caller Information

Bio Parent Information

Goals - *Aim for the goal(s) to be TIED TO THE CRISIS. Guide caller to think about how they can use their own talents and capabilities and what is available to them to bring their family out of crisis and towards stability. Check for goals possibly set with Case Manager from Partnering Agency.

Children to Be Hosted

Other Information to Communicate

Safe Refuge for Children + Families

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