Page 87 - Meeting with Children Manual

P a g e | 1 Child and Youth Intake Form

Child Name____________ File Number _____________

Practitioner Date Parent  Voluntary
Name Understands  Confidential
Location Duration Child  And Exceptions
Session is

CHILD DETAILS FROM PARENT A  PARENT B

Child Full Date of
Name Birth/ AGE
Home Contact
Address #1 Phone
number
Home Contact
Address #2 Phone
Number
School Year at
Attended School

FAMILY AND EXTENDED FAMILY
PARENTS AND STEP PARENTS AND GRANDPARENTS:

Other Parent Relationship Strength /10
Step Parent 1 Relationship Strength /10
Step Parent 2 Relationship Strength /10
Grand Parent 1 Relationship Strength /10
Grand Parent 2 Relationship Strength /10
Grand Parent 3 Relationship Strength /10
Grand Parent 4 Relationship Strength /10
Other Relationship Strength /10

SIBLINGS AND STEP SIBLING:
Name of Child Age
Name of Child Age
Name of Child Age
Name of Child Age
Name of Child Age
Name of Child Age
Name of Child Age

© Lorri Yasenik and Jon Graham 2016
Private and Confidential
We acknowledge and pay respect to the traditional owners and custodians of the land on which we work and live.
The Institute of Specialist Dispute Resolution Pty Ltd
ABN 46 105 820 791
PAGE 85