SKORE Intake Parent/Guardian Information Question Title * 1. Youth Name Question Title * 2. Guardian's Name Question Title * 3. Guardian Date of Birth? Date / Time Date Question Title * 4. Your Relationship to the Youth Biological Parent Grandparent Legal Guardian Adoptive Parent Temporary Guardian Other Other (please specify) Question Title * 5. What is your Marital Status? Single Married Divorced Separated Widowed Partner Question Title * 6. Your cell number? If you don't have one, type N/A Question Title * 7. What is your email address? If Unknown Type N/A Question Title * 8. If you currently work, please list your employer/occupation. Question Title * 9. Guardian 2 Question Title * 10. Guardian 2 Date of Birth Date / Time Date Question Title * 11. Relationship to the Youth Biological Parent Grandparent Legal Guardian Adoptive Parent Temporary Guardian Other Other (please specify) Question Title * 12. Alternate cellphone Number? If unknown, type N/A Question Title * 13. Select all that apply. I/We have: Physical Custody Joint Custody Guardianship Legal Guardianship Question Title * 14. If known, Biological Mother Highest Level of Education Completed Below 8th 8th 9th 10th 11th High School Diploma Some College College Degree Graduate Degree Question Title * 15. If known, Biological Father's Highest Level of Education Completed Below 8th 8th 9th 10th 11th High School Diploma Some College College Degree Graduate Degree Question Title * 16. What is your street address? Question Title * 17. What city do you live in? Question Title * 18. What is your zip code? Question Title * 19. Do you own or rent this property? Own Rent Question Title * 20. Does either parent/guardian in the household use tobacco products? Yes No Question Title * 21. If you answered yes, would you, or others in your family, be interested in quitting? Yes No Question Title * 22. Excluding your child and yourself, is there anyone else living in your home? Yes No If yes, who? List "name- age- relationship" Question Title * 23. Do you have any other children NOT living in your home? Yes No If yes, list "name- age- relationship" Next
