Minor Intake Form

Minor's Name
D/O/B
Age
Social Security #
Pregnant?
Due date if pregnant
Are there any behavioral concerns we need to be aware of? If yes, explain.
Are there current or past criminal charges? If yes, explain.
Are there any mental health concerns? If yes, explain.
Are there any substance abuse issues? If yes, explain.
If this is a new placement why is she changing placements?
Has a physical been completed on the minor within the last six months?
Has this child lived in group living environment before?
Has the minor been prepared for what group living will involve?
What belongings will she be bringing? (Can only bring clothing and personal effects, no tv's, etc.)
Does she have clothing and personal hygiene care products?
Is the minor currently taking any medications? (Dosage and time)
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