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CSKT Intake Form

PRIMARY PARENT/GUARDIAN INFORMATION
First Name(*)
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Last Name(*)
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Street Address/PO Box(*)
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City(*)
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State
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Zip Code(*)
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Phone(*)
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Cell
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Email(*)
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Sex(*)
Invalid Input

Date of Birth
/ / Invalid Input

Ethnic Category(*)
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Race(*)
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Select which ever applies, if any.
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Enrollment #
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What other tribe is the primary guardian enrolled in?
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Marital Status(*)
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Referral Source(*)
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Other
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FINANCIAL AND EMPLOYMENT
Monthly Family Income ($)(*)
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TANF or GA Eligible(*)
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F&R Lunch(*)
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Are you currently receiving any financial assistance?(*)
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Please check each type of financial assistance you are currently receiving.(*)
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Amount of SNAP assistance being recieved ($)
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Amount of LIEAP assistance being recieved ($)
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Amount of SSI assistance being recieved ($)
Invalid Input

Amount of SSD assistance being recieved ($)
Invalid Input

Amount of Wages assistance being recieved ($)
Invalid Input

Amount of Unemployment assistance being recieved ($)
Invalid Input

Amount of TANF/GA assistance being recieved ($)
Invalid Input

Amount of Commodities assistance being recieved ($)
Invalid Input

Amount of Other assistance being recieved ($)
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HEALTH INSURANCE (IHS NOT INCLUDED)
Health Insurance
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Applied For
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Referral Made For
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EDUCATIONAL BACKGROUND
Educational Background
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Highest Grade Completed
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BENCHMARK DATA (INTAKE DATA NEEDED UPON ENROLLMENT)
Pregnant?(*)
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Number of weeks pregnanant
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Use of tobacco?(*)
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Number of times using tobacco per week
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Taking vitamins w/Folic Acid?(*)
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Do you use contraception?(*)
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If no, why not?
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Other
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If yes, what method do you use?
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Other
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SECONDARY PARENT/GUARDIAN INFORMATION
First Name
Invalid Input

Last Name
Invalid Input

Street Address/PO Box
Invalid Input

City
Invalid Input

State
Invalid Input

Zip Code
Invalid Input

Phone
Invalid Input

Cell
Invalid Input

Email
Invalid Input

Sex
Invalid Input

Date of Birth
/ / Invalid Input

Ethnic Category
Invalid Input

Race
Invalid Input

 
FINANCIAL AND EMPLOYMENT
Monthly Family Income ($)
Invalid Input

TANF or GA Eligible
Invalid Input

F&R Lunch
Invalid Input

Are you currently receiving any financial assistance?
Invalid Input

Please check each type of financial assistance you are currently receiving.
Invalid Input

Amount of SNAP assistance being recieved ($)
Invalid Input

Amount of LIEAP assistance being recieved ($)
Invalid Input

Amount of SSI assistance being recieved ($)
Invalid Input

Amount of SSD assistance being recieved ($)
Invalid Input

Amount of Wages assistance being recieved ($)
Invalid Input

Amount of Unemployment assistance being recieved ($)
Invalid Input

Amount of TANF/GA assistance being recieved ($)
Invalid Input

Amount of Commodities assistance being recieved ($)
Invalid Input

Amount of Other assistance being recieved ($)
Invalid Input


HEALTH INSURANCE (IHS NOT INCLUDED)
Health Insurance
Invalid Input

Applied For
Invalid Input

Referral Made For
Invalid Input


EDUCATIONAL BACKGROUND
Educational Background
Invalid Input

Highest Grade Completed
Invalid Input


BENCHMARK DATA (INTAKE DATA NEEDED UPON ENROLLMENT)
Pregnant?
Invalid Input

Number of weeks pregnanant
Invalid Input

Use of tobacco?
Invalid Input

Number of times using tobacco per week
Invalid Input

Taking vitamins w/Folic Acid?
Invalid Input

Do you use contraception?
Invalid Input

If no, why not?
Invalid Input

Other
Invalid Input

If yes, what method do you use?
Invalid Input

Other
Invalid Input

 
MIECHV/TARGET CHILD INFORMATION
First Name(*)
Invalid Input

Last Name(*)
Invalid Input

Street Address/PO Box(*)
Invalid Input

City(*)
Invalid Input

State
Invalid Input

Zip Code(*)
Invalid Input

Sex(*)
Invalid Input

Date of Birth(*)
/ / Invalid Input

Ethnic Category(*)
Invalid Input

Select which ever applies, if any.
Invalid Input

Enrollment #
Invalid Input

What other tribe is the child enrolled in?
Invalid Input


HEALTH INSURANCE (IHS NOT INCLUDED)
Health Insurance
Invalid Input

Applied For
Invalid Input

Other
Invalid Input

Date of last Well-child visit(*)
Invalid Input

Number of child visits to the ER in the last six months?(*)
Invalid Input

Reason(s) for child's visit(s) to ER?
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Number of women's visits to the ER in the last six months?
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Reason(s)?
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Has parent had annual doctor visit?(*)
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Has child had an annual doctor visit?(*)
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SIBLINGS IN THE HOME
Number of Children
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Ages of Children
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NATIONAL HIGH NEEDS CHARACTERISTICS
Check any that apply.

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ADDITIONAL DEMOGRAPHIC CHARACTERISTICS
Check any that apply.

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Additional Notes
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(*)

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Mission & Vision Statement

Our Vision: All children will learn, grow and develop to realize their full potential.

Our Mission: A parent as Teachers promotes the optimal early development, learning and health of children by supporting and engaging their parents and caregivers.

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