Fostering Family General Intake Form Intake forms are securely encrypted and HIPAA compliant. Fostering Family: General Intake Form ID # CLIENT FIRST NAME*CLIENT LAST NAME*DOB: MM slash DD slash YYYY EMAIL* SEX* FEMALE MALE OR: PLEASE SPECIFY:RACE/ETHNICITY*SS NUMBER*PREFERRED LANGUAGE*MARK ALL THAT APPLY* MINOR SINGLE MARRIED DIVORCED STUDENT EMPLOYED EMPPLOYER/SCHOOL*ADDRESS*CITY*STATE*ZIP*MAILING ADRESS (IF DIFFERENT)CITYSTATEZIPPHONE*PHONE 2IS THE CLIENT UNDER 18 YEARS OLD?* YES NO IF UNDER 18: NAME OF LEGAL REPRESENTATIVE & RELATIONSHIP TO CLIENT:*EMERGENCY CONTACT NAME/RELATION*EMERGENCY CONTACT PHONE*PSYCHIATRISTPSYCHIATRIST PHONEPRIMARY CARE PHYSICIANPRIMARY CARE PHYSICIAN PHONE