HIPPY Program - Client Intake Form

Miami


Please fill out the form below, and someone from our office will be in touch once your application has been reviewed.  If you prefer to download a paper copy and send it back via fax, you can do so by clicking here.


 

Applicant Information (Parent Information)

mm/dd/yyyy
At least one phone number is required in order for your application to be considered.
Race
Ethnicity
Languages Spoken
If you selected "Other" please list them here.
Relationship to Child (REN)
Marital Status
If you answered "other" please explain.
Highest Education Level
If you answered "other" please describe.
Best time to contact

Child(ren) Information

mm/dd/yyyy
Gender
Learning, Emotional, Profound, Physical, Sensory
Does the child have health insurance?
Enrolled in subsidized Pre-K / Childcare?
mm/dd/yyyy
Gender
Learning, Emotional, Profound, Physical, Sensory
Does the child have health insurance?
Enrolled in subsidized Pre-K / Childcare?
If you are interested in enrolling more than 2 children, please provide the same information for any additional children.

Family Information

Either Annual Income OR Monthly Income must be provided.
Council of Accreditation