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Intake Questionnaire

Required

Student Namerequired
First Name
Middle (optional)
Last Name
Student's Preferred Pronouns:
Student's Cell Phone Number
Must contain a date in M/D/YYYY format
Student's Address:required
Number and Street Name
Apartment/Unit/Floor #:
City
State
Zip Code
Contact Information:required*Please list in the order you would like to be contacted
1. First Name
Last Name:
Relationship to Student:
Phone number
Email address
*Please list in the order you would like to be contacted
For contact person number 1, please check if the answer is YES:requiredPlease select up to 3 choices
Please select up to 3 choices
Contact Person #2
First Name:
Last Name:
Relationship to student:
Phone Number:
For contact person number 2, please check if the answer is YES:Please select up to 3 choices
Please select up to 3 choices
Contact Person #3
3. First Name
Last Name:
Relationship to Student:
Phone Number
For contact person number 3, please check if the answer is YES:Please select up to 3 choices
Please select up to 3 choices
Contact Person #4:
4. First Name
Last Name:
Relationship to Student:
Phone Number
For contact person number 4, please check if the answer is YES:Please select up to 3 choices
Please select up to 3 choices
Ethnicity (Select One):required
Race (Select all that apply):required
Is the child in DCF custody or is DCF involvedrequired
If YES, please provide:
Case Worker's Name:
Case Worker's Phone Number or Email Address:
Is the student on probation?required
Does the student have an active IEP or 504 Plan?required
Does the student or has the student ever had a Behavioral Intervention Plan?required
Has the student ever had a safety plan?required
Has the student ever been arrested?required
Is the student a parent or an expectant parent?required
Has the student been in treatment for mental health or substance abuse:required
Must contain a date in M/D/YYYY format
Is the student currently seeing a therapist?required
Does the student currently have a mentor?required
Does the student currently see a psychiatrist?required
Does the student currently have internet access at home?required
Does the student feel comfortable using a computer?required

Please have the student and guardian complete this next section. Please check which apply. *All responses are confidential.*

Is the student:

Moody/agitatedrequired
Anxious/worriedrequired
Depressed/unhappyrequired
Hyperactive/inattentiverequired
Shy/withdrawnrequired
Aggressive behaviorsrequired
Stealsrequired
Completes school work at homerequired
Low test/assignment gradesrequired
Disruptive classroom behaviorsrequired
Does not like schoolrequired
Likes to participate in classrequired
Sleeping in class/always tiredrequired
Sudden change in gradesrequired
Frequently tardy to schoolrequired
Frequently absent from schoolrequired
Difficulty taking uprequired
Cuts classrequired
Defiant/disrespectuflrequired
Please check yes or no for the following.
*All responses are confidential.*
Do you have food insecurity?required
Have you been bullied?required
Do you have difficulty with family members?required
Do you have issues with substance abuse?required
Is there gang involvement?required
Is there a history of trauma?required
Do you have housing instability/homelessness?required
Does the student currently work?required
Does the student play sports or participate in extracurricular activities?required
Transportation:required