Child & Family Intake Form

Child's Full Name:

Birth Date:
Food Allergies:
Health Allergies:

Preferred Nickname:

Mother/Guardian's Name:
Do you live in the same home as your child? Y / N
Place of Employment:
Father/Guardian's Name:
Do you live in the same home as your child? Y / N
Place of Employment:
Siblings:
Name:
Name:
Name:
Name:
Others that live in the home:
Name:
Name:
Name:

DOB:
DOB:
DOB:
DOB:

Relationship:
Relationship:
Relationship:

The following questions are optional. I ask so that I can be culturally sensitive to all
the children and families in my care.
1. What is your religion?
Where do you attend services?
2. What is your ethnicity?
3. Do you have ethnic and/or cultural influences in your home? Y / N
If yes, explain:

4. List any specific religious/ethnic/cultural items you'd like discussed or

not-discussed with your child.
(i.e. When a person passes away, do they go to
Heaven? Are they reincarnated? Religious holiday's - specify celebrated and
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non-celebrate. etc.)

About Your Child

Does your child have any specific fears? Y / N If yes, what?
Does your child have any diagnosed or suspected, medical or emotional disorders/
developmental issues (slow or advanced)? Y / N
If yes, explain:
Are there areas you would like your child to focus on?
(i.e. potty training, school readiness, socialization, temperament, gross motor, etc.)
Are there any restrictions in play or activities? Y / N
If yes, explain:
How do you handle discipline at home?
How does your child behave when ill?
How does your child feel about child care? And about being dropped off by Mom or
Dad?
Is drop-off time usually a smooth transition? Y / N
If no, what is your current routine at drop-off time?

Bedtime
What is your child's usual bedtime?
Nap time?
Duration:
Does your child have a special blanket or toy for nap? Y / N
If yes, what?
Does your child sleep through the night? Y / N

Waking time?

Potty Training
Is your child potty trained, can he/she be relied upon to indicate bathroom needs?
Y / N. If yes or N/A, please skip to the next section.
Are you in the process of potty training? Y / N
If yes, please take the time to explain your process, so we can keep your
child moving forward with their development.

If no, do you plan to start soon? Y / N

If yes, when?
What are the words that you and your child use for potty training?
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Bowel movement:
Soiled Diaper:

Urination:

Please take the time and list a "typical" day for your child:

What are your expectations of me and my child care?

Thank you for taking the time to full all this out. ( I know it repetitive with some other forms
you need to fill out). This form will really help me to give your child the best care possible.
Let me know if you have any question or concerns.
Thank you again,
Jen Langer
715 273-3439
jlanger@hughes.net