picture of T and Grandma JaneFAMILY FRIENDS

Family (Initial) Intake

please complete and click the "Submit" button at the bottom to send completed form to Family Friends

Name (caregiver)  Email Address: Date:

Note: Email addresses will only be used to provide updates and will not be sold or shared with other entities.

Address: City: State: Zip:
Home phone:   Work or cell phone:
How did you hear about Family Friends?

Information on Child

Name: Age:

Diagnosis or Disability:

What about Family Friends made you interested?

How many children living in the home:
What are their names and ages?
Does your child with disabilities go to school?
What type of therapy, if any ?    Therapy provided
Childs interests:
Dislikes:
What would you most need your Family Friend to help with?

Household Information

Best times for visits (possible interview)?
Religious preference (if any)?
Pets in home?
Smoking in home?
Comments: