Street Child Intake Form
Use this form to record a child's basic details, current situation, immediate needs, safety concerns, and follow-up notes for outreach support.
Intake Details
Preferred name or identifier
*
Estimated age or age range
*
Gender identity
Please Select
Female
Male
Non-binary
Prefer not to say
Other
Current Situation
Current location or usual sleeping area
*
How long has the child been on the street or without stable housing?
Please Select
Less than 1 week
1–4 weeks
1–3 months
3–12 months
More than 1 year
Unknown
Who is the child currently accompanied by?
Please Select
Parent
Guardian
Relative
Alone
Needs and Safety
Immediate needs
*
Food
Water
Shelter
Clothing
Medical help
Family tracing
Education
Other
Urgent safety concerns
*
Preferred follow-up contact method
Phone
Text message
Through a trusted adult
Community worker visit
No contact preferred
Other
Submit
Should be Empty: