Child Information Form Client ID#______

CHILD INFORMATION FORM Non-Residential Programs 7/15 Client ID______Household ID Number______First Contact Date______Case Close Date:______This form must be completed within 24 hours of intake. A. CLIENT DEMOGRA PHICS

1. Name:______

2. Mother’s/Guardian’s Name:______ Other: 3. Gender  Female  Male ______ Not Reported (Client declined) Identity: ______

 Transgender female (male to female): Someone whose sex is or was male but identifies as female

 Transgender male (female to male): Someone whose sex is or was female but identifies as male

 Genderqueer/Gender non-conforming: Someone who does not identify exclusively as male or female, somewhere in between or neither gender identity

4. Age at First Contact: ______ Non-  Hispanic/Latin 5. Ethnicity: Hispanic/Non o  Unknown Latino  Native 6.Race: Check as  American  Asian  Black/African Hawaiian/Oth many as Indian or  White American er Pacific  Unknown apply Alaska Native Islander

7.Custody:  Client Has  DCFS Has  Joint-Offender  Offender Has Custody Custody Custody and Client  Other  Other:______ Unknown Relative Has ______Custody

8.Lives With:  Client  Client &  Offender  Other  Other______ Unknown Offender Relative ______

st nd rd th th th th th th th th th 9.School: Not Of School Age Pre-school Kindergarten 1 2 3 4 5 6 7 8 9 10 11 12 Graduated Dropout Unknown

10. DCFS:  DCFS Open  DCFS Investigation B. NONCASH BENEFITS/HEALTH INSURANCE: 1. Non Cash Benefits:  Food  TANF Stamps/food  Other Source benefit card (Link Transportation Card)  Special  Other TANF Supplemental  No Non Cash benefits funded services nutrition (WIC)  Section 8,  TANF Child public housing,  Unknown Care services rent assistance 2. Health Insurance  State  Medicaid children’s health health insurance insurance  Private health insurance (18 and older only) (Children’s Medicaid)  Veteran’s  Medicare administration  No health insurance health insurance med services

 Unknown C. SPECIAL No special needs NEEDS (as many Unknown Not Reported as apply): indicated  Is hearing  Limited  Requires special diet impaired English (primary language:______)  Requires  Requires a  Other special need:______assistance in wheelchair feeding, dressing, or toileting  Must have  Has ______medications immobility administered  Is visually  Has impaired-requires developmental assistance disability D. SERVICES NEEDED: Check all services needed by child.  Shelter  Emotional/Co  Child care  Medical Advocacy unseling  Housing  Individual  Legal  Crisis Intervention Support Services  Financial  School  Employment  Transportation Advocacy (child)  Referral  Group Activity  Legal  Parent Child Support (child) Advocacy  Lock up/Board  Education  Medical  Community Advocacy up Services  Therapy

E. CHILD’S  No Behavioral Issues Observed from any of the categories BEHAVIO RAL ISSUES Emotional Physical Social Educational (if in school)  Is often afraid  Bed-wets (if  Plays with fire  Misses school often not due to medical reasons  Can’t leaving over age 4)  Tries to act  Has dropped out of school parent  Illnesses like a parent  Has problems obeying rules at school often (role reversal)  Accepts  Special Class behavioral problems without  Weight  Is very question problems protective of  Has learning problems  Cries often  More active family  Special Class learning problems members  Mood swings than other children  Resists  Little If yes, in guidance and interaction  special class discipline  Nightmares  Abuses drugs  Is possessive  Hurts self on of toys (if age Abuses purpose  3 or older) alcohol  Suicidal  Hits, kicks,

CHILD INFORMATION FORM Non-Residential Programs 7/15 bites, shoves frequently  Behaves like a younger child  Harms animals

F. RESIDENCE Address:______City/town Township County State Zip Code (Enter UK for Unknown and NR for Not reported)

Mother/Guardian Signature______Date______

Counselor Signature______Date______