Form | Family Matters

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Intake Interview Information

When was the date of the last contact with the child(ren)?

What is the understanding of the reasons why you were referred to Family Matters? (check all that apply)

Allegations, threats or history of violence/stalking Alcohol or Substance Abuse History

Child Abuse Allegations Neglect/Threatening

Sexual Abuse Allegations Inconsistent/Unreliable Person or Place

Lack of Access/Alienation of the child(ren) Poor Parenting Skills

Abduction Risk (threatened or attempted) Homelessness or Displaced Family

Other

Is the child(ren) aware of the court order and why they are coming to Family Matters?

Yes

What do you anticipate the child(ren)’s response to coming to Family Matters? (happy, sad, scared, angry, shy, etc.)

What can we do to make this a good experience for them?

First name

Last name

Preferred Name

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Phone

Attorney:

What is your relation to the child(ren)?

Child's Full Name

Child's Age

Name child prefers to be called:

Race/Ethnicity:

Gender

Birthday

Child's Full Name

Child's Age

Name child prefers to be called:

Race/Ethnicity:

Gender

Birthday

Child's Full Name

Child's Age

Name child prefers to be called:

Race/Ethnicity:

Gender

Birthday

Child's Full Name

Child's Age

Name child prefers to be called:

Race/Ethnicity:

Gender

Birthday

Who does the child(ren) currently live with?

What is their relation to the child? (Check as many as apply)

Mother

Father

Grandparent

Other Family Member

Foster Parent

Legal

Guardian/Custodian

If this person someone other than you or a parent, please list their name(s) and phone number here:

1st Parent or Mother's Full Name:

1st Parent or Mother's Address:

1st Parent or Mother's best numbers:

1st Parent or Mother's Email:

1st Parent or Mother's Attorney:

2nd Parent or Father's Attorney:

2nd Parent or Father's Address:

2nd Parent or Father's best numbers:

2nd Parent or Father's Email:

I accept terms & conditions

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Thanks for filling out form. We will be contacting you soon.

Business Cell: 502.471.8110

Email: familymatterscontact@gmail.com

1300 W. Muhammad Ali Blvd.

Ste. 202

Louisville,Ky 40203

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