Child Information Form

Child Name:*

First Last

Parent/Guardian Name:*

First Last

Preferred Contact Method:

Cell Phone #:

Email Address:

My child participates in extracurricular activities:*

Yes
No

Additional Information:

My child has a mental health diagnosis:*

Yes
No

Additional Information:

My child has a medical diagnosis:*

Yes
No

Additional Information:

My child has been in trouble with law enforcement:*

Yes
No

Additional Information:

My child enjoys school:*

Yes
No

Additional Information:

My child has an IEP at school:*

Yes
No

Additional Information:

My child has experienced one or more out of home placements:*

Yes
No

Additional Information:

My child has run away from home:*

Yes
No

Additional Information:

My child takes daily medication:*

Yes
No

Additional Information:

My child has a history of suicidal thoughts or statements:*

Yes
No

Additional Information:

My child has experienced one or more traumatic events:*

Yes
No

Additional Information:

My child has experienced the loss of a significant relationship (through death, divorce, a move):*

Yes
No

Additional Information:

During the last 2 years, have you had concerns about any of the following with your child?:*

Dishonesty
Drug or Alcohol Use
An Unhealthy Friend Group
Trouble at school
Failure to follow household rules
Involvement with law enforcement
Significant mental health concerns or treatment
None of the above

Additional Information:

Are any of the following barriers for your family in participating in the Kinship relationship?:*

Transportation
Work Schedules
Phone Access
Activity Schedules
Child Care
None of the above

Additional Information:

Is your child available to meet with a mentor at least 6 hours per month for at least a year?:*

Yes
No

Additional Information:

Does your child have any physical health problems?:*

Yes
No

Additional Information:

Is there anyone your child is NOT allowed to have contact with?:*

Yes
No

Additional Information:

Do you share custody of your child with anyone?:*

Yes
No

Additional Information:

Date

Signature

Type Name

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