Extended Packet For Consultations – Break Through Learning Center

Parent Interview Form

Today's Date*

Date of Birth:

Case Number:

Report to:

Name*

First Middle Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone*

Work Phone

Cell Phone

Email Address

Enter Email Confirm Email

Ethnicity or Culture

Emergency Information, Name:*

Emergency Information, Phone:*

Please Check One*

Visiting Parent
Non-Visiting Parent

List Children: By Name, Age and Custodial Parent:

ie: With You, Ex-Partner, Foster Care, Residential Care, With a Family Member

Name	Age	Custodial Parent	Co-Parent

List other people living in your home:

ie: Roommates, In-Laws, Friends, Partners, Step-Children, Foster Children, Nanny, Etc.

Describe in detail what you are looking for:

i.e. volunteer because of problems, divorce, separation, social worker recommended, court-ordered etc

What document ordered or recommended our services? Be specific.

Tell us if there is any history of drug/alcohol abuse, sexual or neglect accusations against you.

Are there any criminal issues pending such as restraining orders, court hearings for termination or divorce proceedings?

Any special need kids in your home?

Describe stresses such as job problems, divorce/relational issues, parent/child conflicts, etc.

How do you believe children should be disciplined? Be specific. Describe given choices, punished, have consequence, experience out comes, etc.

Do you have any questions?

Consent To Release Of Information

I hereby authorize Break Through Learning Center to disclose information regarding participation in parenting classes, parenting plans, mediation, consultation or parent coaching or supervised visitation to all parties listed below:*

Name	Address	Email	Phone

I give permission to Break Through Learning Center and to individuals and/or all organizations listed above including all agents of DSHS or Criminal or Family Court officials to exchange information about my completion of class assignments, absences, educational assessments, visits and recommendations. I, give permission for the following person or persons to drop off and pick up my child from visitation as agreed on in the intake plan:*

Name	Address	Email	Phone

Consent To Realease of Information

The purpose of this release of information is to allow the individuals or organizations information used primarily for case monitoring and/or court compliance or for information disclosed to a GAL/VGAL, parent evaluator or social worker for parent assessments. Release of information shall, unless earlier revoked, expire in 12 months from the date consented.

I agree to the Consent to Realease of Information

Refusal to Release Information

I do not give permission for the release of information as described above. However, I understand that, if I do
not allow my facilitator to exchange information about me, that may limit their ability to fully coordinate my education and fulfill requirements made by social service agencies or courts.

I DO NOT agree to the Consent to Realease of Information