Custody Intake Information Sheet
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CUSTODY INTAKE INFORMATION SHEET
Child(ren)’s Information:
1.
_______________________________
____/____/___
____
____
_______________________
Child’s name
Birthdate
Age
Sex
Person child lives with now
_______________________________
____/____/___
____
____
_______________________
Child’s name
Birthdate
Age
Sex
Person child lives with now
_______________________________
____/____/___
____
____
_______________________
Child’s name
Birthdate
Age
Sex
Person child lives with now
_______________________________
____/____/___
____
____
_______________________
Child’s name
Birthdate
Age
Sex
Person child lives with now
Mother:
Father:
2.
3.
__________________________________________
_____________________________________________
Last name,
First,
MI
Last name,
First name,
MI.
__________________________________________
_____________________________________________
Number
Street
Apt.
Number
Street
Apt.
__________________________________________
_____________________________________________
City
State
Zip code
City
State
Zip Code
_____/_____/_____
________________
_____/_____/_____
_________________
Birthdate
Phone #
Birthdate
Phone #
Father:
How was Paternity Established? (Circle One)
4.
(Additional if necessary)
_________________________________________
CSEA
Affidavit
Juvenile Ct. Case
Last name,
First,
MI
Probate
Never Done
_________________________________________
Case # or Paternity Registry #: _____________________
Number
Street
Apt.
_________________________________________
Child(ren)’s Legal Custodian (other than parents):
5.
City
State
Zip code
___________________________________________
_____/______/_____
_________________
Last name,
First
Birthdate
Phone #
____________________________________________
Street
____________________________________________
City
State
Zip code
How was Paternity established? (
_________________
____________________
Circle One)
Birthdate
Phone #
CSEA
Affidavit
Juvenile Ct. Case
Probate
Never Done
Case # or Central Paternity Registry #:________________
6. Have the above noted parents ever been married to each other?
YES NO
If YES,
_____________
Divorced? YES
NO
please specify the date of the marriage
Are they
If YES,
_____________________
when was the divorce final
CONFIDENTIAL
7. Applicant:
Relationship to the child__________________________
____________________________________
_______________
Staff Use Only
Last Name
First name
Birthdate
___________________________________________________
Case#______________________________
Number
Street
Apt.
Paternity Case #_______________________
___________________________________________________
Family #______________________________
City
State
Zip code
Phone #
Checked By:______ Accepted By:________
Revised 02/2009
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Parent category: Legal