KIDS

EARLY YEARS CHILD'S INFORMATION FORM
1242 Market Street, 2nd Floor, San Francisco, CA 94102-4802
(415) 437-0700 or 1-800-392-9239 FAX: (415) 437-0796

PLEASE PRINT OUT THIS FORM, PRINT OR TYPE your information and return this form and the parent form(s) to Kids' Turn at the above address with a signed consent form and your payment.

Name of parent completing this form: ______________________________

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Child's Name: ______________________________Gender: ______Boy ________Girl

Child's Age: __________ Date of birth: ________________

1. Who typically cares for your child during the day?

Daycare/Preschool (Name) ___________________

Friend/relative_____________ Other____________

Parent(s) _________________________________

2. Approximately what amount of time does your child spend with each parent?

__________with you ______________with the other parent

3. Ethnicity (Optional) ______________________________

3. Name(s) and age(s) or brother(s) and/or sister(s):

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4. What are your observations of your child's reactions to this separation or divorce?

5. What most concerns you about your child at this time?

6. Please circle the response that most closely indicates the extent to which you agree or disagree:

a. I have a good understanding of my child(ren)'s reactions to the separation.