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*CLIENT DOB MM slash DD slash YYYY EMAIL* SEX* FEMALE MALE OR: Please SpecifyRACE/ETHNICITY*SS NUMBER*PRIMARY LANGUAGE*CHECK ALL THAT APPLY* CHILD NEVER MARRIED MARRIED DIVORCED STUDENT EMPLOYED EMPLOYER/SCHOOL*RESIDENTIAL ADDRESS*CITY*STATE*ZIP*MAILING ADDRESS (If Different)CITYSTATEZIPPHONE 1*PHONE 2IS THE CLIENT UNDER 18 YEARS OF AGE?* YES NO IF UNDER 18: GUARDIAN NAME + RELATION*DO ANY ADDITIONAL FAMILY MEMBERS REQUIRE SERVICES?* YES NO EMERGENCY CONTACT NAME/RELATION*EMERGENCY CONTACT PHONE*PSYCHIATRISTPSYCHIATRIST PHONEPRIMARY CARE PHYSICIANPRIMARY CARE PHYSICIAN PHONE
