"Intake Form" - South Dakota

Intake Form is a legal document that was released by the South Dakota Department of Education - a government authority operating within South Dakota.

Form Details:

  • Released on October 1, 2013;
  • The latest edition currently provided by the South Dakota Department of Education;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the South Dakota Department of Education.

ADVERTISEMENT
ADVERTISEMENT

Download "Intake Form" - South Dakota

988 times
Rate (4.6 / 5) 49 votes
INTAKE FORM
Date Referral Received:_____________________
SOURCE OF INTAKE REQUEST
Name of referring person/agency: ______________________________________
Phone: ______________________
FAMILY INFORMATION
Child's name: ___________________________________________ Male____ Female____
DOB_____/_____/_____
Child’s Address:_______________________________________________________________________________________
Guardian:
(If other than parent)________________________________________________________________________________________________
Mother's name: _______________________________________ Phone: (H) _________________ (W) _________________
Address: ____________________________________________________________________________________________
Father's name: ________________________________________ Phone: (H) ___________________ (W) _______________
Address: ____________________________________________________________________________________________
Directions to family's home: _____________________________________________________________________________
Medical Diagnosis :
________________________________________________________________________________
(If any)
Family physician:_____________________________________________
Phone: ____________________________
CONCERNS OF REFERRAL SOURCE
____________________________________________________________________________________________________
CONCERNS OF PARENTS
__________________________________________________________________________________________
CURRENT SERVICES (check all apply)
___ Childcare Services 
              ___ Food Stamps 
___ Preschool Services   
___ CHIP (Children’s Health Insurance
        ___ Head Start/Early Head Start     ___ Respite Care Program 
 Program 
              ___ Home Health Care
___ Shriners 
___ Legal Aid
___ SSI 
___ Children’s Special health Services       
 
               ___ Medicaid
               ___ Subsidized Housing 
___ 
___ Energy Assistance & Weatherization   ___ Medical Insurance
___ Support Groups 
___ Family Support Program 
___ Mental Health Counseling           ___ TANF 
        ___ Parenting Classes
___ WIC 
Other 
___________________________________________________________________________________ 
Intake 10/13
INTAKE FORM
Date Referral Received:_____________________
SOURCE OF INTAKE REQUEST
Name of referring person/agency: ______________________________________
Phone: ______________________
FAMILY INFORMATION
Child's name: ___________________________________________ Male____ Female____
DOB_____/_____/_____
Child’s Address:_______________________________________________________________________________________
Guardian:
(If other than parent)________________________________________________________________________________________________
Mother's name: _______________________________________ Phone: (H) _________________ (W) _________________
Address: ____________________________________________________________________________________________
Father's name: ________________________________________ Phone: (H) ___________________ (W) _______________
Address: ____________________________________________________________________________________________
Directions to family's home: _____________________________________________________________________________
Medical Diagnosis :
________________________________________________________________________________
(If any)
Family physician:_____________________________________________
Phone: ____________________________
CONCERNS OF REFERRAL SOURCE
____________________________________________________________________________________________________
CONCERNS OF PARENTS
__________________________________________________________________________________________
CURRENT SERVICES (check all apply)
___ Childcare Services 
              ___ Food Stamps 
___ Preschool Services   
___ CHIP (Children’s Health Insurance
        ___ Head Start/Early Head Start     ___ Respite Care Program 
 Program 
              ___ Home Health Care
___ Shriners 
___ Legal Aid
___ SSI 
___ Children’s Special health Services       
 
               ___ Medicaid
               ___ Subsidized Housing 
___ 
___ Energy Assistance & Weatherization   ___ Medical Insurance
___ Support Groups 
___ Family Support Program 
___ Mental Health Counseling           ___ TANF 
        ___ Parenting Classes
___ WIC 
Other 
___________________________________________________________________________________ 
Intake 10/13