CHILD INFORMATION FORM

Residential Shelter Programs 7/15

Client ID______Household ID Number______

First Contact Date______Case Close Date:______

This form must be completed within 24 hours of intake.

A. CLIENT DEMOGRAPHICS

1.  Name:______
2.  Mother’s/Guardian’s Name:______
3. Gender Identity: / q  Female / q  Male / q  Other:______/ q  Not Reported (Client declined)
q  Transgender female (male to female): Someone whose sex is or was male but identifies as female
q  Transgender male (female to male): Someone whose sex is or was female but identifies as male
q  Genderqueer/Gender non-conforming: Someone who does not identify exclusively as male or female, somewhere in between or neither gender identity
4. Age at First Contact: ______
5. Ethnicity: / q  Non-Hispanic/Non-Latino / q  Hispanic/Latino / q  Unknown
6.  Race: Check as many as apply / q  American Indian or Alaska Native / q  Asian / q  Black/African American / q  Native Hawaiian/Other Pacific Islander / q  White / q  Unknown
7.  Custody: / q  Client Has Custody / q  DCFS Has Custody / q  Joint-Offender and Client / q  Offender Has Custody
q  Other Relative Has Custody / q  Other:______/ q  Unknown
8.  Lives With: / q  Client / q  Client & Offender / q  Offender / q  Other Relative / q  Other______/ q  Unknown
9.  School: / Not Of School Age Pre-school Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Graduated Dropout Unknown
10.  DCFS: / q  DCFS Open / q  DCFS Investigation
B. NONCASH BENEFITS/HEALTH INSURANCE:
1. Non Cash Benefits:
q  Food Stamps/food benefit card (Link Card) / q  TANF Transportation / q  Other Source
q  Special Supplemental nutrition (WIC) / q  Other TANF funded services / q  No Non Cash benefits
q  TANF Child Care services / q  Section 8, public housing, rent assistance / q  Unknown
2. Health Insurance
q  Medicaid health insurance (18 and older only) / q  State children’s health insurance (Children’s Medicaid) / q  Private health insurance
q  Medicare health insurance / q  Veteran’s administration med services / q  No health insurance
q  Unknown
C. SPECIAL NEEDS (as many as apply): / q  No special needs indicated / q  Unknown / q  Not Reported
q  Is hearing impaired / q  Limited English (primary language:______) / q  Requires special diet
q  Requires assistance in feeding, dressing, or toileting / q  Requires a wheelchair / q  Other special need:______
q  Must have medications administered / q  Has immobility / ______
q  Is visually impaired-requires assistance / q  Has developmental disability
D. SERVICES NEEDED: Check all services needed by child.
q  Shelter / q  Emotional/Counseling / q  Child care / q  Medical Advocacy
q  Housing / q  Individual Support / q  Legal Services / q  Crisis Intervention
q  Financial / q  School Advocacy (child) / q  Employment / q  Transportation
q  Referral / q  Group Activity (child) / q  Legal Advocacy / q  Parent Child Support
q  Lock up/Board up / q  Education / q  Medical Services / q  Community Advocacy
q  Therapy

E. CHILD’S BEHAVIORAL ISSUES

/ q  No Behavioral Issues Observed from any of the categories
Emotional
q  Is often afraid
q  Can’t leaving parent
q  Accepts without question
q  Cries often
q  Mood swings
q  Little interaction
q  Nightmares
q  Hurts self on purpose
q  Suicidal /

Physical

q  Bed-wets (if over age 4)
q  Illnesses often
q  Weight problems
q  More active than other children
q  If yes, in special class
q  Abuses drugs
q  Abuses alcohol /

Social

q  Plays with fire
q  Tries to act like a parent (role reversal)
q  Is very protective of family members
q  Resists guidance and discipline
q  Is possessive of toys (if age 3 or older)
q  Hits, kicks, bites, shoves frequently
q  Behaves like a younger child
q  Harms animals / Educational (if in school)
q  Misses school often not due to medical reasons
q  Has dropped out of school
q  Has problems obeying rules at school
q  Special Class behavioral problems
q  Has learning problems
q  Special Class learning problems
F. RESIDENCE / /
Address:______
______
City/town Township County State Zip Code
(Enter UK for Unknown and NR for Not reported)
Type of Residence (IMMEDIATELY prior to coming to dv shelter/transitional housing program) (shelter/transitional housing clients only)
q  Emergency shelter (other dv or homeless) / q  Substance abuse treat. facility / q  Staying/living w/family member / q  Place not meant for habitation
q  Transitional housing-homeless / q  Jail/prison/juvenile detention ctr / q  Staying/living w/friend / q  Other
q  Perm. housing for formerly homeless / q  Room/apt/house rented / q  Hotel/motel paid for w/o emergency shelter voucher / q  Unknown
q  Psychiatric hospital/facility / q  Apt/house owned / q  Foster care home/group home / q  Not Reported
Length of stay in previous place (place indicated above) (shelter/transitional housing clients only)
q  One week or less / q  One week to one month / q  1-3 months / q  More than 3 months, up to 1 year / q  One year or longer / q  Unknown
PREVIOUS SERVICE USE (shelter/transitional housing clients only): In The Last Year….
1—Has the child used another domestic violence shelter in this part of IL? YES NO If yes, about how long ago (approx date):______
2—Has the child used another homeless shelter in this part of IL? YES NO If yes, about how long ago (approx date): ______

Mother/Guardian Signature______Date______

Counselor Signature______Date______

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