Date:

First name: Last Name:

Address:  

City:   State: Zip:

DOB:   Sex:

Current Phone:  

Alternate Phone:

School and grade:

Parents or Guardians' name(s):

Who has legal custody:

Address if Different:

Phone if different:

Referred By:   

Phone:

If DSS case, has abuse been substantiated ? Yes No

Or is it a family "In need of services" ? Yes No

IF DSS CASE, PLEASE ADVISE THEM TO FORWARD

WRITTEN CONFIRMATION OF LEGAL CUSTODY AND

SUBSTANTIATION OR FAMILY "IN NEED OF SERVICES"

Date of abuse:  

Alleged perpetrator:

Details of Abuse:

Medicaid: Yes No   If yes provide #

Insurance Yes No   If yes policy #