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42,..1 I <br /> LtL <br /> A, <br /> PARENT INFORMATION SHEET <br /> Child Name ! Date of Birth <br /> Address <br /> Home Phone <br /> Child's School Grade/year in <br /> school <br /> Was your child adopted? ❑ Yes ❑ No <br /> Parents <br /> Mother's Occupation <br /> Name <br /> Marital History <br /> Address(if different from above) <br /> Home Phone(if different from above) Is it okay to leave a ❑Yes ❑ No <br /> message? <br /> Cell Phone Is it okay to leave a ❑Yes ❑ No <br /> , message? <br /> Work Phone Is it okay to leave a ❑Yes ❑ No <br /> message? <br /> Father's <br /> Occupation <br /> Name <br /> Marital History <br /> Address(if different from above) <br /> Home Phone(if different from above) ❑Yes 0 No <br /> i Is it okay to leave a <br /> message? <br /> Cell Phone Is it okay to leave a ❑Yes ❑ No <br /> message? <br /> Work Phone Is it okay to leave a ❑Yes ❑ No <br /> message? <br /> PLEASE LIST THE PEOPLE YOUR CHILD LIVES WITH AND OTHER IMMEDIATE FAMILY MEMBERS NOT IN THE HOME: <br /> NAME ` 1 AGE ; :RELATIONSHIP TO CHILD DOES HE/SHE LIVE IN THE HOME? <br /> ❑Yes ❑ No <br /> • <br /> ❑Yes ❑ No <br /> ❑Yes ❑ No <br /> • <br /> ❑Yes ❑ No <br /> ❑Yes ❑ No <br /> • ❑Yes ❑ No <br /> ❑Yes ❑ No <br /> ❑Yes ❑ No <br /> ........... <br /> ❑Yes ❑ No <br /> a _.. <br /> ❑Yes ❑ No <br /> What are your primary concerns regarding your child at this time? When did you first begin to have these concerns? <br /> Page 1 of 3 <br />