Page 88 - Meeting with Children Manual

P a g e | 2 Child and Youth Intake Form

Child Name____________ File Number _____________

CURRENT LIVING ARRANGEMENTS
Parent  Not separated Comments
Relationship  Separated informally
 Separated same roof
 Physical separated
 Never together
Living  Shared Parenting/Equal Shared Comments
Arrangement Time
Type  Substantial and Significant Time
o Amount Time with Parent 1
o Amount Time with Parent 2
 Other

CHILD DEVELOPMENT CONCERNS

Is the parent
aware of any
developmental
concerns for the
child (Physical,
emotional, social
cognitive)
Has the child Medications taken and
received any purpose
diagnoses

CHILD NEEDS FROM THIS PROCESS
 Parent Notes:  Parent Notes:
observation of observation of
the child’s the child’s
needs from this needs from
process #1 this process #2

 Parent Notes  Parent Notes:
observation of observation of
the child’s the child’s
needs from this needs from
process #3 this process #4

© 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 86