Intake & Assessment Forms

Adoption Intake Form (Washoe Tribe of Nevada and California) – An adoption intake form with information about adoptive parents and children.

Child Abuse and Neglect Assessment (Sac and Fox Nation) – A modifiable child abuse and neglect assessment including income and expenses and space for case notes.

Child and Family Assessment (Osage Nation) – A brief questionnaire about the family, including contact information, housing, budget, and parenting styles.

Child Intake Form (Rosebud Sioux Tribe) – An evaluation report about the Rosebud Sioux Tribe’s Defending Childhood Initiative; a draft child intake form is on page 35.

Child Support Services Application (Delaware Tribe of Indians) – A child support services application outlining parent and child information, child support payments, and a financial affidavit.

Family Violence Services Intake Form (Citizen Potawatomi Nation) – An intake form for family violence services, including assistance request, perpetrator description, history of abuse, and legal information.

Home Assessment – A modifiable home assessment form.

Legal Aid Application (Colorado River Indian Tribe) – An application for legal services, including a child custody supplement.

Program Eligibility Determination – A modifiable program eligibility determination template.

Alcohol/Drug At-Risk Behavior Survey (Osage Nation) – A survey to assess if a child may have substance abuse issues. 

Child Behaviors Questionnaire (Osage Nation) – A questionnaire for documenting a child’s behavior.

Child Well-Being Questionnaire (Osage Nation) – A questionnaire for documenting a child’s well-being, medical history, and interests.

Education Questionnaire (Osage Nation) – A questionnaire for documenting a child’s education.

Parent/Guardian Health Questionnaire (Osage Nation) – A brief health questionnaire for parents/guardians.