Child/Youth Interest Form
To Be Completed By Child or Youth Referred to CPC
Child/Youth Information
What is your legal name?
First Name
Last Name
What name do you prefer to go by?
What pronouns do you use?
she/her/hers
he/him/his
they/them
ze/hir/hirs
Or list in your own words
Thoughts About School
What do you look forward to the most when you go to school?
What class do you enjoy going to the most?
What class do you NOT look forward to attending?
What is something you would want to change about school?
Do you have an adult at school that you feel comfortable talking to about things?
Are you involved in activities at school or have you been in the past? What were they?
Things About Home and Neighborhood
What are some things you enjoy doing with your family?
What social media or online platforms do you enjoy using?
What do you enjoy watching?
What do you like to do for fun?
If you were outside all day, what activity would you like to do?
Things About Me
What kind of job do you want to have someday?
What are you really good at?
How would you describe yourself?
Tell us about a time you were really excited about something?
Who do you call when you need to talk?
What do you think you need help with?
Finish this sentence: Life will look better when ________.
If you could change anything (family, friends, school, or situation) what would it be?
Signature
Date
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Month
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Day
Year
Date
Submit
Should be Empty: