Service Intake Application

Full Legal Name *

First

Middle

Last

Date of Birth *

Applicants Personal Information

Each Adult must complete an Intake Form and pay the non-refundable service processing fee of $95, prior to commencement of services.

Specify Relationship to Child(ren): *

Cell Phone Number *

Email *

Housing: *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Do you own a vehicle? *

Vehicle Make & Model

License Plate Number *

Vehicle Color

Are you employed? *

Employer / Business Name *

Employer Phone *

Employer Address

Address Line 1

Address Line 2

City

State

Zip Code

Applicants Legal Information

Case Number *

Are you the Custodial or Noncustodial parent? *

Custodial
Noncustodial

Noncustodial Name *

Custodial Name *

Date of Birth *

Court Location/County *

Next Court Date / Time *

Date

Time

Do you have contact with other party? *

Yes
No

Status of communication with other parent: *

Contact information for other party available? *

Yes
No

Please provide any contact information for other party you have. *

Email or cell phone number of other party.

Is there a Restraining Order in Place? *

Yes
No

Restraining Order Expiration Date *

Do you have an attorney? *

Yes
No

Attorney's Phone *

Attorney's Name *

Cultural Information

Race / Ethnicity: *

Emergency Contact Information

In the event parent is incapacitated or not able to be reached the emergency contact can be communicated with.

Emergency Contact Name *

Emergency contact other than parent.

Emergency Contact Relationship *

Emergency Contact DL/ID Number *

Emergency Contact Cell phone number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Children's Information

Number of Children involved: *

Child #1 Name *

Child #1 Date of Birth *

Child #1 Gender

Child #1 Allergies / Dietary Restrictions *

Child #1 Medical Conditions *

Child #1 Hair and Eye Color

Child #1 Doctor Name & Phone Number

Child #2 Name *

Child #2 Date of Birth *

Child #2 Gender *

Child #2 Hair and Eye Color

Child #2 Allergies / Dietary Restrictions *

Child #2 Medical Conditions *

Child #3 Name *

Child #3 Gender *

Child #3 Date of Birth *

Child #4 Name *

Child #4 Date of Birth *

Child #4 Gender *

Additional Child(ren) Information *

Child(ren) Address *

Address Line 1

Address Line 2

City

State

Zip Code

Applicants Personal Information

Applicants Legal Information

Cultural Information

Emergency Contact Information

Children's Information

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