Family Interview & Intake Form

Please complete this comprehensive form to help us understand your family's needs, rules, and emergency procedures.

Family Information and Emergency Numbers

Today's date:

Family Name/Name of Parents or Guardians:

Home phone number:

Mobile phone number:

Address:

E-mail address:

Nearest cross street:

Child's name, Age, and Weight:

Medicines, Allergies, and Medical problems:

Phone number where parent can be reached during caregiving job:

Name and phone number of an adult who can make decisions if parent cannot be reached:

Neighbor's name and phone number:

Doctor's name and phone number:

Name of preferred hospital to be used in an emergency:

What are the household rules? How would you like me to handle misbehavior?

Do the children need to complete any homework or chores? If so, when, and will they need assistance?

Does your family have a fire escape plan? Where are the shut-off valves for water, electricity, and gas?

Is it OK to take the children outside? Should I apply insect repellent or sunscreen (and what kind)?

What are your family's rules for play, watching TV, using the computer, and playing video games?

Where is your first aid kit and emergency preparedness kit kept?

What can your children eat and drink? Will I be preparing any simple meals?

What are the routines for diapering, using the toilet, quiet time, bedtime, and naps?

Are there any other specific care needs or routines I should know about (e.g., tutoring, music/sports practice)?