aisintakeform

							                     ADOLESCENT INTERVENTION SERVICES
                                                    Case
                                             Intake Form
                             PARENT/GUARDIAN INFORMATION:

Parent/Guardian Name:

Street Address:
City:                                         State:                            Zip:
Home Number:                                  Work Number:
Cell/Pager                                Fax Number:
Email Address

Pick-Up Address same as above? Yes or No
If NO, Where:

CUSTODY: (Dual full/Maternal Joint/Paternal Joint/Sole Legal/Guardian)
______________________________________________________________________

Parent/Guardian Name:

Street Address:
City:                     State:                   Zip:
Home Number:                              Work Number:
Cell/Pager:                                   Fax Number:
Email Address:



                                   ADOLESCENT INFORMATION:

Name:                              DOB:                     Age:

Height:          Weight:                  Hair Color:              Eye Color:
Distinguishing Marks:
Image/Dress:
Has own Cell Phone: YES or NO

Physical Skill Level: Very Athletic    Somewhat Athletic      Inactive
Previous Transports: YES or NO If Yes, When/Where:
Any Attitudes or Behaviors during previous transport?:



                                    REFERRAL INFORMATION:

Referred By:
Name of Ed. Consultant:
Contact Number:
                   SCHOOL OR PROGRAM CHILD WILL BE ATTENDING:

Name of School/Program:
Contact Person:                                     Phone Number:
Address:

Driving or Flying Child?   YES or NO or BOTH
Airport Pick-Up? YES or NO
Nearest Airport from Pick-Up Location?


                              REASONS FOR GOING TO PROGRAM:

Precipitating Events:

Substance Abuse:                             Smokes: YES or NO
Behavioral:
Violent Behavior:
Access to Weapons:
Suicidal:
Any Attempts? .
Self-Mutilation:

Arrest Record:                                                  Probation:
Probation Officer Name:                                     Number:



                               MEDICAL/PSYCHIATRIC PROFILE:

Medical History:
Psychiatric History or Counseling:
Clinical Assessment (Any Disorders):
Medication:
Type/How Much:

Moods/Behaviors?: Aggressive or Passive     Respectful or Disrespectful
Compliant or Non-Compliant    Verbal or Non-Verbal

Physically Acting Out?:    YES or NO     How:



                          ANY ADDITIONAL INFORMATION/REQUESTS:
                                 SOCIAL BACKGROUND:

Siblings:
Friends:
Gang Affiliation:
Boyfriend/Girlfriend:
Likes:
Sports:
Dislikes:
Any Prejudices:
Any Recent Losses:
Any Goals for the Future:



      ___________________________________________________________
                      *AIS OFFICE USE ONLY:

                            TRANSPORT AGENT INSTRUCTIONS:




AGENT INFORMATION:
Lead Agent                                         Contact Number
Back Up Agent                                  Contact Number

NOTE TO ALL AGENTS : PLEASE CONTACT PROGRAMS PRIOR TO ARRIVAL
TO GIVE ETA & A QUICK ASSESSMENT OF THE CHILD. PLEASE GIVE
COMPLETE ASSESSMENT OF TRANSPORT WHEN YOU ARRIVE AT PROGRAM.
PLEASE CONTACT ED CONSULTANTS AFTER LEAVING PICK
UP POINT AND LEAVE A MESSAGE. ALSO, CONTACT THEM AT END OF CASE
WITH BRIEF ASSESSMENT . ( ONLY IF CONSULTANT LISTED ON INTAKE).
THANK YOU