Guardian Angel Intake Form	Date:
Are You The Legal Parent/Guardian:	SELECT ONE Yes No
First Name:
Last name:
Marital Status:	SELECT ONE Married Divorced Widow(er) Divorced/Remarried Widow(er)/Remarried
Relationship to Minor:	SELECT ONE Biological Parent Adoptive Parent Step Parent Legal Guardian Other
Email:
Cell Phone:
Home Phone:
Work Phone:
Alternate Phone:
When Calling Me Use:	SELECT ONE Cell Home Work Alternate
Fax Phone:
Address:
City:
State:
Zip Code:
Minor's First Name:
Last Name:
Date of Birth:
Height:
Minor's Weight:
Eye Color:
Hair Color:
Hair Style:
Distuingishing Marks:	Scars,tattoos',body piercings:
Physically Fit:	SELECT ONE No Average Very
Social Comfort:	SELECT ONE Shy Average Very
Confrontational:	SELECT ONE Never Somewhat Very
Violent:	SELECT ONE Never Sometimes Often
Divorce/Adoption Issues:	SELECT ONE Adoption Divorce Both
Criminal Convictions:	Please explain:
Behavioral/School Problems:	Please explain:
Medical Conditions:	Please explain:
Psychiatric History:	Please explain:
Current Medication(s) & Dosage:	Please explain:
Relationship/Death Issues:	Please explain:
Suicide Threats/Attempts:	Please explain:
Previous Intervention(s):	Please explain:
Present Location:
Destination:
Referred By:
I/we attest under oath that I/we have FULL LEGAL CUSTODY of above named child. Furthermore, I/we avow said child is allowed to leave the state he/she is currently residing in and is not confined to or under the supervision of this state or any governing agencies within it. By initialing this document I/we am/are confirming that ALL of the above given information is true. Parent/Guardian Initials Parent/Guardian Initials