Parent/Guardian Name *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Child's Name: *

First Name

Last Name

Legal Guardian: *

First Name

Last Name

Additional Legal Guardian

First Name

Last Name

Phone Number *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date seen at Cherish: *

MM

DD

YYYY

DCS Contact

First Name

Last Name

Law Enforcement Contact

First Name

Last Name

Name of Individual Completing Form *

First Name

Last Name

Date Completed: *

MM

DD

YYYY

I understand: *

- Cherish has an obligation to keep my personal information, identifying information, and my records confidential. I also understand my information will be shared among the Cherish Multidisciplinary Team in order to provide effective case management and I can choose to allow Cherish to release some of my personal information to certain individuals or agencies. - I do not have to complete a release form. I do not have to allow Cherish to share my information. Completing a release form is completely voluntary. - Releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from Cherish. - The risks and benefits of releasing the confidential information to the above organization or person. - A limited release of information can potentially open up access by others to my confidential information held by Cherish. - The specific information I want to be released and how it will be shared. I understand email is not confidential. - Cherish and I may not be able to control what happens to my information once it has been released and that the agency or person getting my information may be required by law or practice to share with others. - This release is valid when I check this box and complete this form and I may withdraw my consent to this release at any time either verbally or in writing. By checking this box and submitting this form, I acknowledge I have read these policies and I consent to services and/or referrals from Cherish. I authorize the release of the above stated information to Cherish. I further understand that this is not an acceptance of services and that Cherish has an ethical obligation to respect my right to privacy through the handling of information in a confidential manner. By completing this form I agree to complete a post survey regarding the services provided. I hereby consent to authorize the release of information aforementioned.

I have read these policies and I consent to services and/or referrals from Cherish.

1. Serious national disaster like a flood, tornado, hurricane, earthquake, or fire. *

Yes

No

2. Serious accident or injury like a car/bike crash, dog bite, sports injury. *

Yes

No

3. Robbed by threat, force, or weapon. *

Yes

No

4. Slapped, punched, or beat up by someone in the family. *

Yes

No

5. Slapped, punched, or beat up by someone not in the family. *

Yes

No

6. Seeing someone in the family get slapped, punched, or beat up. *

Yes

No

7. Seeing someone in the community get slapped, punched, or beat up. *

Yes

No

8. Someone older touching his/her private parts when they shouldn’t. *

Yes

No

9. Someone forcing or pressuring sex, or when she/he couldn’t say no. *

Yes

No

10. Someone close to the child dying suddenly or violently. *

Yes

No

11. Attacked, stabbed, shot at, or hurt badly. *

Yes

No

12. Seeing someone attacked, stabbed, shot at, hurt badly, or killed. *

Yes

No

13. Stressful or scary medical procedure. *

Yes

No

14. Being around war. *

Yes

No

Other stressful or scary event? *

Yes

No

1. Upsetting thoughts or images about a stressful event. Or re-enacting a stressful event in play.

0

1

2

3

2. Bad dreams related to a stressful event.

0

1

2

3

3. Acting, playing, or feeling as if a stressful event is happening right now.

0

1

2

3

4. Feeling very emotionally upset when reminded of a stressful event.

0

1

2

3

5. Strong physical reactions when reminded of a stressful event (sweating, heart beating fast).

0

1

2

3

6. Trying not to remember, talk about or have feelings about a stressful event.

0

1

2

3

7. Avoiding activities, people, places, or things that are reminders of a stressful event.

0

1

2

3

8. Increase in negative emotional states (afraid, angry, guilty, ashamed, confusion).

0

1

2

3

9. Losing interest in activities she/he enjoyed before a stressful event. Including not playing as much.

0

1

2

3

10. Acting socially withdrawn.

0

1

2

3

11. Reduction in showing positive feelings (being happy, having loving feelings).

0

1

2

3

12. Being irritable. Or having angry outbursts without a good reason and taking it out on other people or things.

0

1

2

3

13. Being overly alert or on guard.

0

1

2

3

14. Being jumpy or easily startled.

0

1

2

3

15. Problems with concentration.

0

1

2

3

16. Trouble falling or staying asleep.

0

1

2

3

1. Getting along with others

Yes

No

2. Hobbies/Fun

Yes

No

3. School or daycare

Yes

No

4. Family relationships

Yes

No

5. General happiness

Yes

No