Diversion Intake Form

*This portion to be completed by youth

Full Name
D.O.B.
Address
City
State
Zip
Home Phone
Your Cell #
Parent/Guardian
Ethnicity:
Who do you live with?
 Parent  Grandparent  Other
 
List all others who live in the home with you and who they are to you (brother, sister, cousin, etc.)
School
Grade
List your current GPA
Have you been suspended?
 Yes  No
 
How many absences have you had this school year?
Tardies?
Have you been disciplined at school? If yes, list below the reasons
Are you currently enrolled in special education classes?
 Yes  No
 
Are you on an IEP or 504? If yes, for what?
List all school activities you are involved in including sports
Do you have a Drivers License?
 Yes  No
 
Do you have access to a car?
 Yes  No
 

 

Please rate relationships in your life on a scale from 1 to 5, with 1 being the worst and 5 being the best

How well do you get along with your parents?
 1  2  3  4  5
 
How well do you get along with your siblings?
 1  2  3  4  5
 
How well do you get along with your friends?
 1  2  3  4  5
 
How well do you get along with your teachers?
 1  2  3  4  5
 

 

*This portion to be completed by parent

Mother's Name

If mother's address is different than youth's please fill out:

Address
City/State/Zip
Mother's phone number
Cell phone

 

Father's Name

If father's address is different than youth's please fill out:

Address
City/State/Zip
Father's phone number
Cell phone
Parents marital status
 Married  Divorced  Separated  Other
 

 

If there is a stepparent in the home, please list name
Do childís grandparents reside in home?
 Yes  No
 
Number of siblings in home
Does youth have contact with non- custodial parent?
 Yes  No
 
If yes, how often?
Please list all concerns you have for your child to include behavior, academic, etc.
What are your hopes and expectations for this program for you and your child?
List any other concerns or information you believe is valuable and needs to be shared
Is your youth currently on medication?
 Yes  No
 
If yes, please list medications and what they are for

 

Has the referred youth attended counseling?
 Yes  No
 
If yes, are they still attending?
 Yes  No
 
Please list below where they have attended counseling, for how long and for what reasons
Did counseling help or resolve the issue(s)?
 Yes  No
 

 

To the best of your ability, please describe below the relationship you have with your child. Include your perception of how they get along with their siblings, peers, and any adults including authority figures in their life.