Family & Children'S Services Demographic Information
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1
2FAMILY & CHILDREN’S SERVICES DEMOGRAPHIC INFORMATION
Directions: Complete the following information for the person seeking services.
Date Completed:
Client Last Name
Client First Name
Client Middle Name
Sex
Male
Female
Maiden Name (female only)
Social Security Number
Date of Birth (mm/dd/yyyy)
-
-
/
/
Marital Status
Legal Guardian Name
Legal Guardian Relationship
Married
Living as Married
Divorced
Separated
Never Married
Widowed
Legal Guardian Contact Phone
Is Client in Custody Of:
Family ID, DOC #, or DHS Case Number
OJA
DHS
DOC
None
Case Worker Name
Case Worker Phone Number
County of Jurisdiction
Custody:
Foster Care
Not in out-of-home placement
Specialized Community Group Home
Group Home
Residential Treatment
Other
Client Address
Zip Code
City / State
County
Is Client in Prison or Jail?
No
Jail
Prison
Home Phone
Cell Phone
Work Phone
Reminder Call
Yes
No
Reminder Call Number
Email Address
Communication Preference
Cell
Home
Home Phone
Cell Phone
Work Phone
Work
Regular Mail
Email
Do Not Contact
Client Race
Hispanic / Latino
Does Client Speak English Well?
Primary Language
Yes
No
Yes
No
Religion
Is Client Currently in School?
Education / Grade
School Name
Yes
No
Employment Status
Occupation
Full-time
Not in Labor Force
Competitive
Disabled
Homemaker
Inmate
None
Part-time
Unemployed
Retired
Student
Transitional
Volunteer
Other
Sheltered Workshop
Daily Tobacco Use (How Much)
Smoker
Current Every Day
Current Some Day
Former Smoker
Heavy Tobacco Smoker
Light Tobacco Smoker
Never Smoked
Smoker
Unknown if ever smoked
Is Client Pregnant?
If Pregnant, Expected Due Date:
Yes
No
For Office Use Only:
Client Name:
Client Number:
Demographic Information UN98 09/22/14
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Parent category: Business