Fillable CLIENT INFORMATION

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CLIENT INFORMATION

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The CLIENT INFORMATION form is 2 pages long and contains:

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  • 60 check-boxes
  • 33 other fields

Country of origin: OTHERS
File type: PDF

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DATE: COUNSELOR:
CLIENT INFORMATION
CLIENT NAME:
______________________________________________________________________________________
CALLER NAME: (If not parent) _____________________________ AGENCY: (If caseworker)
_________________________
I AM THE: MOTHER FATHER FOSTER PARENT* GRANDPARENT CASEWORKER
GUARDIAN OTHER: ___________________________________________
HOUSEHOLD: SINGLE PARENT 2 PARENTS GRANDPARENT/OTHER RELATIVE
TEEN PARENT FOSTER PARENT OTHER: _____________________________________________
LANGUAGE SPOKEN IN HOME: ENGLISH OTHER: _______________________________________
PHONE NUMBER: ___ CELL HOME WORK
EMAIL: ____________________
ADDRESS: ____________________apt._______________
CITY: _____________ ZIP: ______
OTHER ADDRESS: (If you want care near another address, such as work, school etc.)
__ __________________________
REASON YOU ARE LOOKING FOR CHILD CARE JOB SEEKING JOB SCHOOL END
LEAVE OTHER: ___________________________________
CARE NEEDED NEAR: HOME WORK/SCHOOL/TRAINING PUBLIC TRANSPORTATION
RECEIVING HELP FROM DOWNTOWN TO PAY FOR CHILD CARE: YES NO
HOW DID YOU HEAR ABOUT US: PROVIDER DSS OTHER AGENCY
RELATIVE/FRIEND EMPLOYER 211 INTERNET/CCRN WEBSITE HEALTHCARE
PROFESSIONAL OUTREACH EVENT RADIO/TV SCHOOL DISTRICT/STAFF NO
INFORMATION OTHER: ____________________
CHILD INFORMATION
DATE CARE NEEDED: NOW DATE: _________
BIRTHDATE: BIRTHDATE:
BIRTHDATE: BIRTHDATE:
BIRTHDATE: BIRTHDATE:
TYPE OF CARE: CENTER FDC GFDC SACC CAMP
MEDICATION NEEDED DURING CARE: NO YES
SPECIAL NEEDS: (If you know) NO YES:
TRANSPORTATION: NO PROVIDED IT WOULD BE NICE PROVIDED BY SCHOOL
DISTRICT
DAYS OF WEEK: Mon-Fri Sat Sun TIMES: AM / PM - TO
AM/PM
CARE NEEDED: FULL TIME PART TIME FULL YEAR SCHOOL YEAR
SUMMER ONLY
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CLIENT INFORMATION

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Completed 6 December 2021

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