Guided Pathways Intake Form Step 1 of 4 25% Name:* First Last Date of Birth: MM slash DD slash YYYY Child's Name: First Last Date of Birth: MM slash DD slash YYYY Returning Client: Yes No Address: Street Address Address Line 2 City ZIP / Postal Code School district: School: Grade: Phone Number:E-mail:* How do you prefer to be contacted? Phone E-mail Text None of the above Preferred method of communication:Fill this field out if 'None of the above' was selected in the previous question What days/times are you available for appointments?Monday Morning Afternoon Evening Tuesday Morning Afternoon Evening Wednesday Morning Afternoon Evening Thursday Morning Afternoon Evening Friday Morning Afternoon Evening What services are you interested in? Caregiver Peer Support Youth Peer Support Parent Classes Advocacy Resources and Referrals Volunteering Training/Skill Building Community Social Events DirectionsFor the remaining fields: If you are the caregiver of a youth, fill out the remaining fields with information about yourself. If your youth is going to participate in our youth peer program, we will provide them with their own intake form. If you are a youth, fill out the remaining fields with information about yourself. Caregiver Demographic Information: American Indian/Alaska Native Asian/Asian-American Black/African-American/African Native Hawaiian/Pacific Islander White Hispanic Mixed Race Race Prefer Not to Say Preferred Language Interpreter Required? Yes No Gender Identity: Male Female Self-describes in another way Prefer not to say Gender Detail: Experiencing Homelessness? Yes No Do you experience a disability of any kind? Yes No Prefer Not to Say Physical Disability: Yes No Hearing Impairment: Yes No Vision Impairment: Yes No Developmental Disability: Yes No Cognitive Disability: Yes No Behavioral Health Disability: Yes No HiddenSensory or Communication Disability: Yes No Other Disability Not Listed: Yes No Disability Detail: Education Level: Did Not Complete High School High School/GED 2 Year Degree 4 Year Degree Post-Graduate Education Prefer Not to Say Military: Yes No Prefer Not to Say Household Income: Less than $25,000 $25,000 - $49,999 $50,000 - $74,999 $75,000 - $99,999 $100,000 - $149,999 $150,000 or more Prefer not to say Caregiver Relationship: Biological Parent Adoptive Parent Foster Parent Sibling Aunt or Uncle Grandparent Friend (adult) State Social Worker No Caregiver School Attendance: Infrequent (<50%) More often than not (50-75%) Regular (>75%) Youth not in school How did you hear about us? Web search Pediatrician Mental Health Counselor/Therapist School Friend/Family Member CCORS WISE King County ARY/BECCA Programs Suicide PreventionDue to the alarming increase in suicide throughout our community, Guided Pathways wants to support individuals who may be struggling with thoughts of suicide or self-harm. Your response is optional but your answers will help our staff to provide better assistance.Are you currently thinking about suicide? Yes No I do not want to answer this section Do you have a plan to commit suicide? Yes No On a scale from 1-5, how likely are you to act on your plan? 1. Very unlikely 2. Unlikely 3. Not sure 4. Likely 5. Very likely Please describe the reason you are seeking services at Guided Pathways-Support for Youth and Families:
