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Anitra's Light Foundation

Client Intake

Full Name

Date of birth

Age

Gender

Ethnicity optional

School Name Grade

SECTION 2: PARENT/GUARDIAN INFORMATION

Names of Legal Guardian

Relationship to Child

Address

Street Address

City

State

Country

Postal Code

Phone *

Email *

SECTION 3: CIRCUMSTANCES OF LOSS

Emergency Contact (Name & Phone):

Name of Deceased Parents

Date of Passing

Relationship to Child

Other

Brief explanation of childs current situation who they live with support system etc

SECTION 4: EMOTIONAL & SUPPORT NEEDS

Has the child received any counseling or therapy?

Yes

No

Does the child currently attend any support programs? If so, please describe:

SECTION 5: ADDITIONAL INFO & CONSENT

How did you hear about Anitras Light Foundation

Photo Upload optional if submitting online

Referred by Case Manager or Counselor?

Yes

No

If yes Name and Contact Info of Referrer

Do you give consent for us to share your child's story (photos/videos) for nonprofit promotion?

Yes

No

Signature of Parent or Guardian

Clear

Printed Name

Date

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Phone *

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