Client Intake Form: Children's Services

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Thank you for your interest in our children’s services at Counting Stars for ages 3–17! Whether you are a family member or a caseworker completing this form, we’re excited to learn more about the child and explore how we can best support their growth, development, and success.

Child's First and Last Name *

Name of Person(s) Completing Form *

If you are not a parent or guardian of the child, please write the name(s) of the parent(s)/guardian(s) here

If you are not a parent or guardian of the child, please write the phone number of the parent(s)/guardian(s) here *

If you are not a parent or guardian of the child, please write the email address of the parent(s)/guardian(s) here

Your Relationship to Child: *

Parent

Legal Guardian

Relative Caregiver

CLTS/CPS/CCS Services Coordinator

Other:

Your Phone Number *

Your Email Address: *

Your Preferred Method of Contact *

Phone Call

Text Message

Best Days/Times to Reach You *

Which type(s) of program are you interested in? *

Center & Community-Based Daily Living Skills

Center & Community-Based Discovery and Career Planning

Transportation (to & from Counting Stars programming)

In-home Daily Living Skills

Unpaid Caregiver Support

Group Caregiver Support

Summer Services Only

Other:

Required

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