SOCIAL INTAKE FORM Purpose: To determine the psycho-social needs of students and make appropriate referrals and case management plans. DEMOGRAPHIC INFORMATION Student Name: Student ID: E-mail: Status: Resident Non-Resident Address: (Include City, State, Zip Code) DOE: DOB: Age: Cell Phone #: ( ) FAMILY BACKGROUND Mother/Guardian Father/Guardian Name: Name: Address: Address: City: City: State: State: Zip Code: Zip Code: Phone #: ( ) #: ( ) Do you have any siblings? Yes No If yes, how many: Do you have any children? Yes No If yes, how many: Provide children’s name(s) and age(s): Name: Age: Name: Age: Name: Age: Name: Age: Has the Job Corps child allotment Who is the day care provider for your child(ren)? Yes No been explained to you? Whom have you lived with for Who raised you? the past year? How long have you Yes No Do you like living there? lived there? If a do you live with your If no, the reason is: Yes No parent? If yes, caseworker’s name: Do you have a caseworker? Yes No Phone #: ( ) Military/Discharge Type: Describe your relationship with the following people (e.g., excellent, good, fair, poor, none): Mother/guardian: Father/guardian: Siblings: Significant other/spouse: Friends: Others (e.g., teachers, bosses, etc.): LEGAL ISSUES Have you ever been in trouble with If yes, for what and when (year): Yes No the police? Are you presently awaiting If yes, for what: Yes No charges, court, or sentencing?
SOCIAL INTAKE FORM Purpose: To determine the psycho-social needs of students and make appropriate referrals and case management plans. DEMOGRAPHIC INFORMATION Student Name: Student ID: E-mail: Status: Resident Non-Resident Address: (Include City, State, Zip Code) DOE: DOB: Age: Cell Phone #: ( ) FAMILY BACKGROUND Mother/Guardian Father/Guardian Name: Name: Address: Address: City: City: State: State: Zip Code: Zip Code: Phone #: ( ) #: ( ) Do you have any siblings? Yes No If yes, how many: Do you have any children? Yes No If yes, how many: Provide children’s name(s) and age(s): Name: Age: Name: Age: Name: Age: Name: Age: Has the Job Corps child allotment been explained to you? Yes No Who is the day care provider for your child(ren)? Who raised you? Whom have you lived with for the past year? How long have you lived there? Do you like living there? Yes No If a do you live with your parent? Yes No If no, the reason is: Do you have a caseworker? Yes No If yes, caseworker’s name: Phone #: ( ) Military/Discharge Type: Describe your relationship with the following people (e.g., excellent, good, fair, poor, none): Mother/guardian: Father/guardian: Siblings: Significant other/spouse: Friends: Others (e.g., teachers, bosses, etc.): LEGAL ISSUES Have you ever been in trouble with the police? Yes No If yes, for what and when (year): Are you presently awaiting charges, court, or sentencing? Yes No If yes, for what: