Guardian Angel

Intake Form

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Intake Form

Guardian Angel Intake Form
Date:
Are You The Legal Parent/Guardian:
First Name:
Last name:
Marital Status:
Relationship to Minor:

Email:

Cell Phone:

Home Phone:

Work Phone:

Alternate Phone:

When Calling Me Use:

Fax Phone:

Address:

City:

State:

Zip Code:

 Minor's First Name:
Last Name:
Date of Birth:
Height:
Minor's Weight:
Eye Color:
Hair Color:
Hair Style:
Distuingishing Marks:
Physically Fit:
Social Comfort:
Confrontational:
Violent:
Divorce/Adoption Issues:
Criminal Convictions:
Behavioral/School Problems:
Medical Conditions:
Psychiatric History:
Current Medication(s) & Dosage:
Relationship/Death Issues:
Suicide Threats/Attempts:
Previous Intervention(s):
Present Location:
Destination:
Referred By:

  I/we attest under oath that I/we have FULL LEGAL CUSTODY of above named child. Furthermore, I/we avow said child is allowed to leave the state he/she is currently residing in and is not confined to or under the supervision of this state or any governing agencies within it.

By initialing this document I/we am/are confirming that ALL of the above given information is true.

Parent/Guardian Initials

Parent/Guardian Initials