Professional Documents
Culture Documents
Family Intake Sheet1
Family Intake Sheet1
Preferred Nickname:
Mother/Guardian's Name:
Do you live in the same home as your child? Y / N
Place of Employment:
Father/Guardian's Name:
Do you live in the same home as your child? Y / N
Place of Employment:
Siblings:
Name:
Name:
Name:
Name:
Others that live in the home:
Name:
Name:
Name:
DOB:
DOB:
DOB:
DOB:
Relationship:
Relationship:
Relationship:
The following questions are optional. I ask so that I can be culturally sensitive to all
the children and families in my care.
1. What is your religion?
Where do you attend services?
2. What is your ethnicity?
3. Do you have ethnic and/or cultural influences in your home? Y / N
If yes, explain:
non-celebrate. etc.)
Bedtime
What is your child's usual bedtime?
Nap time?
Duration:
Does your child have a special blanket or toy for nap? Y / N
If yes, what?
Does your child sleep through the night? Y / N
Waking time?
Potty Training
Is your child potty trained, can he/she be relied upon to indicate bathroom needs?
Y / N. If yes or N/A, please skip to the next section.
Are you in the process of potty training? Y / N
If yes, please take the time to explain your process, so we can keep your
child moving forward with their development.
Bowel movement:
Soiled Diaper:
Urination:
Please take the time and list a "typical" day for your child:
Thank you for taking the time to full all this out. ( I know it repetitive with some other forms
you need to fill out). This form will really help me to give your child the best care possible.
Let me know if you have any question or concerns.
Thank you again,
Jen Langer
715 273-3439
jlanger@hughes.net