Home ยป Child Information Form Child Information Form Child Name:* First Last Parent/Guardian Name:* First Last Preferred Contact Method:Select OneCell PhoneEmailCell 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:DateSignatureType Name Search for:
