BMS Youth Services Center Intake Form

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Please complete this form and consider your submission of this form your release of information to the YSC to work on your behalf to provide services requested. The YSC Coordinator will contact you to collect any additional secure information.

Student Name (Sibling names can be added below) *

Student Birthdate *

YYYY

Street Address *

City, State, Zip Code *

Sibling Name

Sibling Birthdate

YYYY

Sibling Name

Sibling Birthdate

YYYY

Sibling Name

Sibling Birthdate

YYYY

Parent/Guardian Name *

Parent/Guardian Birthdate *

YYYY

Parent/Guardian Cell Phone *

Parent/Guardian Work Phone

Total Number of Adults Living in Household *

Total Number of Children Living in Household *

Please list names of all other adults in the household - Please include a birthdate. Please type NONE if no other adults reside in the home. *

Average Monthly Income for Household/Source of income (Work, Unemployment, Social Security, Child Support, etc.) *

Briefly explain your current situation and why you are seeking help. *

I am a relative or caregiver raising my student (foster parent, adoptive parent, grandparent raising a grandchild, or other kin or non-kinship caregiver etc.) *

Yes

Please identify some strengths you have as a parent/guardian. *

Resilience – The ability to withstand or recover quickly from difficult conditions; I can negotiate for what I need and navigate systems.

Patience – The capacity to accept or tolerate delay, trouble, or suffering without getting angry or upset.

Flexibility – Ready and able to change so as to adapt to different circumstances; accept what is happening in the moment.

Compassion – The ability to translate empathic feelings into action (desire to alleviate suffering).

Optimism – Expect a favorable or positive outcome.

Confidence – Sure of one’s self and one’s abilities.

Organization – Methodical and efficient in arrangement or function.

Ability to Laugh – To easily see and appreciate the humor in the situation.

Supports - I have a support system of friends or family I can rely on

Other:

Required

Please list your preferred contact time. *

Morning

Afternoon

I give my permission for the following agencies, participating with the Fayette County Family Resource and Youth Services Centers, to exchange information and service in meeting the needs of my family. Adult Education * Christians in Community Service * Cooperative Extension Center * Insurance Assistance * Cabinet for Families and Children * Church Based Assistance * Family Care Center * Rental Assistance * Medical/Health Referral * Child Care Council * Community Action Council * God’s Pantry * UK College of Dentistry * Christ Community Cupboard * Comprehensive Care * Health Department * Utilities (KU, Columbia Gas, etc.) Or other agency as requested by family/center. Please initial below authorizing the YSC to contact any agencies on your behalf. *

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