Intake Form

Your name

Address

Mobile Phone

Your email

Date of First Contact with CFS

County Your Case is in

What Office is Working Your Case

Who is Your Social Worker (Name & Phone Number)

Who is Your Social Worker’s Supervisor (Name & Phone Number)

What is Your Case Number (It Should Start with The Letter J)

Who is Your Lawyer (Name & Phone Number)

Who is Your Support System

Are You a Member of a church
—Please choose an option—YesNo

Do You Currently Attend School
—Please choose an option—YesNo

Highest Level of Education
—Please choose an option—ElementaryMiddle SchoolSome High School High School GraduateGEDSome CollegeAssociates DegreeBachelors DegreeMasters DegreeDoctorate (PHD)Trade SchoolVocational Certification

What is Your Living Situation
—Please choose an option—HomelessLiving with Family/FriendsLiving in a ShelterRentOwn

Do You Have Medical Insurance
—Please choose an option—YesNo

What is the Stage of your Case
—Please choose an option—InvestigationRemovalDetention HearingOther

If Other, What Stage is Your Case in

Have You Had any Status Reviews of Your Case
—Please choose an option—YesNo

Are Your Children Currently Detained by CFS
—Please choose an option—YesNo

If Yes, What Date Were They Removed

How Many Children Have Been Removed

List Names and Ages of all Siblings

What is the Recommendation by CFS
—Please choose an option—Reunification ServicesNo Reunification Services

Date of your Next CFT (Children and Family Team) Meeting

Date of Your Next Appointment

What Services or Programs has CFS Recommended You Complete
—Please choose an option—ParentingAnger ManagementAATherapyOther

If Other, What Service or Program was Recommended by CFS

What Services are You Looking to get From Haven’s Future
—Please choose an option—ParentingAnger ManagementAATherapyLegal AidHousing ReferralsEmployment ReferralsAdvocationOther

If Other, What Services are you looking to get from Haven’s Future

Tell Us Your Story

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