Big Brothers Big Sisters Child Intake Form
This is the first step to the child enrollment process at Big Brothers Big Sisters of Metropolitan Chicago. We sincerely appreciate the time you take to fill out this form, as it will help us to determine how we might best be able to serve your child. A Big Brothers Big Sisters team member will be in touch with next steps. Thank you!
Name (First & Last)
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Email Address
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Home Address
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Apt or Unit #
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City, State, Zip Code
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Phone Number (xxx)xxx-xxxx
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Child's Name (First & Last)
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Child's Ethnicity
Child's Sex
Child's Birthdate
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DD
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YYYY
Child's Age
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Child's Grade
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Child's School
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Any plans to move in the next 12-18 months? If yes, do you know when/where you will be moving? What is your moving timeline?
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Who does the child live with? Please list all individuals living in the home.
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Do you work outside the home? If yes, what is your work schedule? If your schedule varies, how far in advance do you know your schedule?
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Is there someone else in your home who helps take care of your child? If so, please list their name and relationship.
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When do you picture your child spending time with their Big Brother or Big Sister?
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Do you share custody of your child with anyone else? If so, please list their name and relationship.
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How does your child do in school? Are there any academic concerns?
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Is your child involved in any after school activities? If yes, please list.
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What are your child's interests?
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Does your child have any behavioral concerns or issues with teachers or other children (fights, bullying, etc)? If so, do they exhibit this type of behavior at home as well?
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Does your child have any medical or emotional conditions? If yes, please explain. When was the most recent reaction or episode? What was the severity?
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Does your child take any medication on a regular basis? If yes, how often do they take it? Do they ever take breaks from taking their medication?
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Does your child carry an epi pen? If so, what is their allergy? How severe is it?
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Does your child see any medical or mental health provider, have an IEP at school, or see a school social worker? If so, please explain how long they have been involved and if you have any plans on switching counselors or therapists.
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How did you hear about Big Brothers Big Sisters?
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