Parent Education Program Intake

Parent Education Program

Service Intake Form
Client/Caregiver Information
Name: *

First Name Last Name
Date of Birth: *

Month Day Year
Date
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Primary Phone Number *
Secondary Phone Number
Work Phone Number
Email *
example@example.com
Race: *
Ethnicity *
Tribal Affiliation
SSN: *
Gender *

Male Female
Primary Language: *
Secondary Language:
Emergency Contact Name: *
Emergency Contact Telephone Number: *
Have you attended any other parenting classes before? *

Yes No
If yes, give year attended and length of course:
What is your form of transportation? *
Is this a reliable means of transportation? *

Yes No
Do you have a disability? *

Yes No
Are you currently enrolled in mental health services? *

Yes No
Work Information
Are you the head of your household? *

Yes No
Employment Status *

Employed F/T Employed P/T Not Currently Working Student On Disability
Please provide the amount you make per year. This information is only utilized for tracking purposes. *
Name of Company *
Job Title *
Current Job Schedule *
Child(ren) Information
How many children do you have? *

Please list each child's name and corresponding information below. Each row must contain information. Fill in each row fully for each of your children. For every additional row that you do not need, please type in N/A under Child's Full Name. This information is private and is used only for tracking purposes. *

	Child's Full Name	Race/Ethnicity	Disability? Select if yes.	DOB	Enrolled in Mental Health Services? Select if Yes
Child 1
Child 2
Child 3
Child 4
Child 5
Child 6
Child 7
Child 8

Current Residence of Child/ren *

Biological Home Foster Care Relative Shelter
If child(ren) is not in the home, please fill out contact information for their legal guardian/caregiver.
Guardian/Caregiver Name *

First Name Last Name
Relationship *
Family Side

Maternal Paternal
Guardian Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Reason Child(ren) was taken out of the home (check all that apply): *

Neglect Suspected Physical Abuse Suspected Sexual Abuse Court Ordered Abandonment/Run-Away Drug Related Alcohol Related Domestic Violence Mental Health Issues Currently Under Investigation Child-Alcohol or Drugs
Other Agencies Involved (check all that apply): *

JPO Social Worker CYFD Investigation: CASA Tribal Services Childhaven Family Advocacte Not Applicable
JPO Caseworker's Name:
JPO Phone:
Social Worker Name:
Social Worker Phone:
CYFD Investigator's Name:
CYFD Investigator's Phone:
CASA Advocate Name:
CASA Advocate's Phone:
Tribal Services Worker:
Tribal Services Worker Phone:
Childhaven Family Advocate Name:
Childhaven Family Advocate Name:
Other:
AUTHORIZATION OF RELEASE OF PROTECTED INFORMATION

I agree to release information on this form to Childhaven, Inc. this information is to be used to determine which services are required and evaluate service effectiveness. I understand that I may cancel this authorization at any time by submitting a WRITTEN request to Childhaven, Inc., except where a disclosure has already been made in reliance on my prior authorization.
Type Name: *
By signing below, you agree that you have advised Childhaven of all questions to the best of your knowledge. *

Clear
Date: *

Month Day Year
Date

Appointment Cancellation and No-Show Policy

Childhaven Parent Education Program
The goal of our Parenting Education Services program at Childhaven, Inc. is to provide support to you and your family which helps you reach your goals. As part of our commitment to you, we strive to fulfill your appointment needs. We ask that you make a commitment by being on-time and present as well as participating during scheduled appointment times. In order to continue to meet your needs, we found that it has become necessary to implement a cancellation/no-show policy when clients fail to keep their scheduled appointment.

***Once a client has three (3) cancellations or no-show appointments, the inactive client procedure will be started, leading to client’s file being closed.

*** Failure to keep in contact with your parent support worker will result in your file being closed.

In order to avoid this result:
- If you must miss an appointment, please contact the Parent Support Worker (PSW) at least 24 hours in advance.
- Appointments that are not cancelled at least 24 hours in advance are considered “No-Show”
- For one-on-one sessions, if located outside of Farmington area, client needs to call PSW, if PSW does not receive a call one (1) hour before appointment time, the meeting will be cancelled.
- Exceptions to this policy are emergencies and/or unavoidable circumstances as determined by Childhaven.
Inactive Client Procedure:
- PSW will call and talk about situation and cancellation policy (1st attempt)
- If messages left on 1st attempt are not returned within one week, a second call will be made (2nd attempt)
- If no response after 1 week of second call, a letter will be mailed out and a copy will be sent to CYFD, PS and/or JPO or other referring agency (3rd attempt)
- If no response to the letter, file will be closed.
I, *
Client/Caregiver Name
, have read the above policy and agree to attend my scheduled

appointment at Childhaven for Parenting Education Program. I understand that having “No-Show” appointments could cause discontinuation of services and other involved agencies will be notified.
Legal Guardian Signature *

Clear
Date *

Month Day Year
Date
CHILDHAVEN’S DOOR IS ALWAYS OPEN AND INDIVDUALS WILL BE WELCOMED BACK TO CHILDHAVEN UPON RETURN

Client Grievance Procedures

Childhaven Parent Education Program
Client/Caregiver Name: *
Policy:
The purpose of the Grievance Procedure is to provide our clients with an acceptable means of expressing any complaints or concerns they may have with Childhaven staff, volunteers and/or contractors.
Procedure:
If a client disagrees with a staff, volunteer or contractor decision and/or their conduct, there should always be an initial attempt to resolve any disputes between the two parties involved.

If the client does not feel the matter was resolved, the client may submit a written grievance to Childhaven, 807 W. Apache St., Farmington, 87401. All written grievances will be placed in the mailbox of the appropriate Program Supervisor. Within 72 hours of receipt, the Program Supervisor will contact the client to discuss the matter. The Program Supervisor’s decision will be in writing, with copies placed in the client’s file and sent to the client, no later than 10 working days.

If the Program Supervisor does not satisfy the client’s needs, the written grievance will be forwarded to the Chief Executive Officer (CEO The CEO will investigate the complaint and contact the client within 10 working days. The CEO’s decision will be in writing, with copies placed in the client’s file and sent to the client, no later than 10 working days. The decision of the CEO will be final.

I have read and understand the Client Grievance Procedures.
Caregiver/Client Signature *

Clear
Date *

Month Day Year
Date

FOOD ALLERGY NOTICE

Childhaven Parent Education Program
Please be advised that the dinner provided for Childhaven’s Parent Education Program is not prepared on site and may contain any of the following ingredients:
- Milk/dairy products
- Eggs
- Wheat
- Soybeans
- Peanuts
- Fish
- Shellfish
- Other allergens
Clients and family members who choose to participate in the free dinner, that have known food allergies or sensitivities to certain ingredients should exercise food judgement when consuming. Childhaven will not be held responsible. If you would like to bring your own food from home, you may do so, we only ask that you clean up after yourself.

I have read and understand that I am responsible for me and my family’s food allergies and have the option to bring my own food if I feel it necessary. I understand that Childhaven will not be held responsible and I will use food judgement when participating in the Parent Education Program’s free dinner.
Client Signature

Clear
Date

Month Day Year
Date

Confidentiality and Respect Agreement

Childhaven Parent Education Program
The Parent Education Program strives to help families learn and improve communication skills, nurturing techniques as well as other necessary parenting practices. In order to learn and improve these skills, we must exercise them. Throughout the course of Nurturing Parenting, there may be times you and your family members are asked to share personal experiences or opinions about certain controversial topics, which you may choose to decline. However, please keep in mind that others in the group also have their chance to be heard and may share opinions that are not the same with your own or they may talk about difficult personal experiences.

We at Childhaven believe that everyone should be granted the respect and freedom to share their thoughts, beliefs, and stories without judgement. Childhaven stands by the confidentiality policy and ask that everyone who participates in the Parent Education Program be mindful of this policy and keeps group discussions in the group, and not share outside of class.

To optimize our group sessions we ask that participants follow these guidelines: Turn off/ silence your cell phone during group discussions Allow each other to speak one at a time Listen to each other, give the speaker you full attention Do not make negative comments or snide remarks Do not discuss someone’s personal stories with others outside the group. Respect other’s backgrounds, religion, beliefs, and values. Do not be confrontational or start an argument Do not intimidate or belittle anyone.

Childhaven reserves the right to refuse or discontinue service to anyone that we deem may have expressed inappropriate behavior and/or broken any of the previous guidelines set forth by the Parenting Education Program.
Client/Caregiver Signature *

Clear
Date *

Month Day Year

Transportation Agreement

Childhaven Parent Education Program
Childhaven’s Parent Education Program strives to meet the needs of all parents and caregivers by providing transportation to and from weekly classes when other forms of transportation is not available. In order for Childhaven to better meet your needs we ask that you:

Call the Friday Before the class before 3:00 PM and schedule a pick up time with a designated Childhaven Staff Member. Let the staff know exact number of passengers Provide home address and physical direction if needed Contain all pets away from Childhaven staff in order to maintain safety. Be ready at scheduled time and place for pick up Always wear a seatbelt and assure that your child(ren) are securely fastened at all times

Provide your own infant car seat or toddler booster seat Clean up after yourself when exiting the vehicle Refrain from smoking (tobacco/ecigs) and chewing tobacco Refrain from consuming alcohol No open food or drinks in the vehicle (unless in sealed container for dinner) Children may not travel without a parent or legal guardian If you need to cancel transportation please call Childhaven at least 24 hours before your scheduled pick up time

I have read and understand that Transportation Agreement and agree to follow the terms set forth by the Childhaven Parent Education Program. I consent to have Childhaven staff come to my residence and transport me and my approved passengers to and from the Parenting Education Classes.
Client/Caregiver Signature *

Clear
Date *

Month Day Year
Transportation is a first come, first served basis and seats are limited. Please assure that you make transportation arrangements by Friday before 3pm.

Services Agreement

Childhaven Parent Education Program
Client/Caregiver Name *
Client/Caregiver Date of Birth *

Month Day Year
Date
The Parent Education Program addresses the strengths and challenges of clients and their families. It provides ongoing support, training, coordination of resources, involving families and the community.

Parent Education Services Include:
- Meeting with the client face - to - face during weekly group sessions or one - on one sessions
- Coordination of services with referring agency
Your involvement in Parent Education Services includes:
- Letting your Parent Support Worker (PSW) know how to reac h you
- Telling your PSW what your needs are
- Participating with your PSW in setting goals and developing a service plan and schedule
- Doing your best to follow this plan and schedule
- Keeping appointments of scheduled classes Participating in post enrollment s urveys
- Contacting PSW in the event of a contagious illness/condition in your home (pinkeye, lice, etc.)
- Refraining from smoking, including e - cigs, during meetings
- If participating in in - home services, keeps pets contained and away from PSW
- Refraining from alcohol or substance abuse while receiving services from the PSW
I have read and understand this consent form. All rules, family and client responsibilities, times and locations of services, guidelines for participation, reasons for termination, client and family rights, and confidentiality procedures have been fully explained. I understand my part and wish to be enrolled in the Childhaven, Inc. Parenting Education Program. I am willing to work closely with my PSW and to follow the plan we will develop together.
Client/Caregiver Signature *

Clear
Date *

Month Day Year
Date

Parent Education Program

Work Information

Child(ren) Information

Appointment Cancellation and No-Show Policy

CHILDHAVEN’S DOOR IS ALWAYS OPEN AND INDIVDUALS WILL BE WELCOMED BACK TO CHILDHAVEN UPON RETURN

Client Grievance Procedures

Policy:

Procedure:

FOOD ALLERGY NOTICE

Confidentiality and Respect Agreement

Transportation Agreement

Services Agreement

Child Information Form (1)

Child Care Information Form (2)

Child Care Information Form (3)