Family Advocate Program Client Checklist

Date*

Date

Time*

:HourMinutesAM/PM Option

Location*

1320 W. Abram, Arlington, TX908 Southland Ave., Fort Worth, TX625 Grapevine Hwy., Hurst, TX8401 Jacksboro Hwy., Lakeside, TX

Caregiver Name*

First NameLast Name

Caregiver Date of Birth*

Date

Caregiver Phone Number*

Area CodePhone Number

Is it ok to leave a voicemail/text?*

YesNo

Email

example@example.com

Is it ok to send an email?*

YesNo

Child's Name 1*

First NameLast Name

Child's Date of Birth*

Date

Child's School/ISD:

Child's Name 2

First NameLast Name

Child's Date of Birth

Date

Child's School/ISD:

Place a checkmark next to any of the following information you would like assistance with for your child, yourself, and/or your family. This will help us understand how we can assist your family.

Housing*

Bills*

Legal*

Stability*

Annual Income:

Physical*

Developmental*

Speech Delay/ImpedimentLearning Disability (Dyslexia, Autism, etc.)OtherNo issues

Behavioral*

Emotional*

Mental Health*

Would you like for a Family Advocate to visit with your child to assess for any indications of self-harm or suicidal thoughts?

YesNo

Academic Concerns*

Other*

If you need asistance with anything else, please list below. Also, feel free to elaborate on any of the above items so we can better assist you. When finished, please click "SUBMIT" button.

Notes

Family Advocate Program Client Checklist

Health Concerns

Other Concerns