SAFE PARTY INTAKE INFORMATION                                             Custodial Party:____ Visiting Party:____    Name:_____________________________ Child(ren's Last Name:___________________    Address: _________________________Apt#____City:_________State:____Zip:_______        Home Ph:_______________Cell #________________Email:________________________    Employer:____________________________________Wk Phone:____________________    DOB:____/____/____  SS#____/____/____ D.L.#___________________State:___________    Automobile Information:    Make:__________Model:___________Lic Plate:__________Yr:________Color:________    Attorney:    Name:_______________________Phone:__________________Fax:__________________    Address:___________________________________________________________________    Amicus (Attorney for the child(ren)    Name:_______________________Phone:__________________Fax:___________________    Address:____________________________________________________________________    Therapist for the child(ren)    Name:_______________________Phone:__________________Fax:___________________    Address:___________________________________________________________________    Parent/Guardian Signature:_______________________________Date:________________