Child Intake | True Reflections Community Development

Parent link

Parent / Guardian (attaches this child to your intake)

These stay filled in after you submit, so you can go straight to your next child.

Parent/guardian full name

Parent Participant ID (if known) (optional)

Phone

Email

This child is number

Total children in family

Section A

Child Information

Child's legal name

Preferred name (optional)

Date of birth

Gender (optional)

Race / ethnicity (optional)

Primary language (optional)

Interpreter needed? (optional)

Clothing / shoe size (optional)

Child currently lives with (optional)

This parent Other parent Relative / kinship Foster care

Other (describe)

Will the child live in a True Reflections residence?

No — visits only Yes Not yet decided

Section B

Custody & Legal

Court orders (custody, protection, no-contact)

None Yes — will provide a copy

Caseworker name (optional)

Caseworker phone (optional)

People who may NOT have contact with or pick up this child (optional)

Staff can only enforce a no-contact restriction when a copy of the court order is on file.

Section C

Emergency Contacts & Authorized Pick-Up

Other than the parent/guardian above.

Name	Relationship	Phone	May pick up? (Y/N)

Photo ID is required at every pick-up.

Section D

Health & Medical

Health insurance / Medicaid (optional)

Policy / ID # (optional)

Doctor / clinic (optional)

Doctor phone (optional)

Dentist (optional)

Immunizations current? (optional)

Allergy details and reaction (optional)

Carries (optional)

EpiPen Inhaler

Medical conditions (asthma, seizures, diabetes, etc.) (optional)

Medication	Dose	Times given	Given during programs? (Y/N)

Dietary needs / restrictions (optional)

Section E

School & Child Care

Section F

Development, Behavior & Well-Being

Section G

Strengths, Interests & Family Goals

Signature

Consents & Signature

I have signed (or will sign) the Parent / Guardian Release for Minors for this child.

Staff may share this child's information with the child's school or doctor only with my separate written release.

I understand True Reflections staff are mandated reporters of suspected child abuse or neglect.

The information on this form is true and complete, and I will tell staff when anything changes.

Type your full name as your signature

Date

Child Intake One form for each child.