Please Complete The Form Below To Begin The Intake Process Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Address *Contact NumberDate of BirthAge of Child at enrollmentSchool Child AttendsSchool DistrictGradeHas this child lost a parent or sibling to homicide?YesNoOtherIf yes, please provide name, and date of homicide of the parent, guardian, or sibling:Any problems with child in school that we should be aware of? If so, please list. Contact Number for parent or guardian:Is your child seeing a therapist? YesNoPlease list the medication your child takes:Any Allergies?Does this child have MO, KS Medicaid? YesNoPrivate Insurance: YesNoEmail Address for parent or guardian enrolling child into program:If you are interested in other children in your home or siblings to the child being registered for services through Circle of Hope, please list name and ages below:Please place a check for the programs offered by Circle of Hope that you would like to see your child involved in:Individual CounselingGroup Support (children are placed in age groups)Mentor &/or Life CoachSpecial Activities (If child is actively participating in programs at Circle of Hope they Automatically qualify for any special activities hosted by COHHow did you hear about Circle of Hope? Any special concerns that you have regarding the child you are enrolling? We will do our best to address these concerns during our various programs.Are you ok if pictures are taken of this child during events? These pictures may be used on the agency’s website, displayed in the office &/or will possibly be used on the news. YesNo*Photo Waivers will be given to you to sign giving your consent to photo ops.STAFF ONLY If child has not attended the funeral yet, please ask the following: Will child need a haircut (simple boys cut) or hair style (simple hair style) Boy: YesNoWill the family like support during planning the services of the deceased?YesNoFuneral Home best Insurance: be Date and Time of ServiceWill the family be interested in a prayer/candlelight vigil?YesNoSingle Line TextIf Yes Please Include The DateBalloon ReleaseYesNoIf Yes Please Include The DateSignature of Parent or Guardian Date of Parent or Guardian SignatureSubmit
