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CHILD/ADOLESCENT INTAKE INFORMATION FAMILY IDENTIFYING INFORMATION SHEET Today s Date Name Child/Adolescent Birth date Age Address Street or P. O. Box City State Zip Code Grade in School School Teacher Counselor Referred by PARENTS Mother Name Birth date Age Relationship to child Biological Step Adoptive Foster Other Present Relationship Status Married Date Home Phone Divorced Date Employer Separated Date Job Title Widowed Date Work Hours Committed Relationship Work Phone Never Married Father...
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