Client intake form

This page is to be used by SGS staff, Certified facilitators, and trained volunteers.  

Read Disclaimer:  The information given on this call is a public service and courtesy. This information shall not be construed as legal, medical, or mental health advice.  By continuing with this conversation, you are agreeing that SGS will not be held liable for any action taken as a result of this call.  SGS reserves the right to report to the proper authorities any incident perceived as a threat or imminent danger to oneself or another person.    

Do you agree to these terms in order to proceed with the call?

Boys Town National Hotline:  1-800-448-3000

National Domestic Violence and Sexual Assault Hotline: 1-800-799-7233

Confidential Trafficking Resource Center Hotline: 1-888-373-7888

Omaha Resources:

WCA - (402) 345-7273

Omaha Police Department -  (402) 444-5600

Omaha FBI - (402) 493-8688

Project Harmony -  (402) 444-5636

Omaha Child Protective Service - (402) 595-3250

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The disclaimer was read and accepted. -Select-YesNo

About the caller.

First Name

Last Name

Email

Cell Phone

Address

City

State Select a StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip Code

Reason for call Digital exploitation, sextortion, and/or abuseMinor self-producing CPMinor in possession of CPMinor found sextingOff-brand Social Media reportQuestion about minor's technologyQuestion about an Application, social media, or a smart phoneQuestion about school's digital policies About SGS ProgrammingFBI referralUNO referralMMI ReferralOther

Program Scheduling Mediation Social Media Audit/ResetDigital Wellness and COVID-19About Smart Gen Society (Free 20 min)Keynote Speaker RequestSmart Digtial Branding, K-3Smart Digtial Branding, 4-5Smart Digtial Branding, 6-8Smart Digtial Branding, 9-12Smart Digtial Branding, CollegeParenting the Smart GenEducating the Smart GenSmart Digital Branding for Businesses

About the minor.

Is the child safe? YesNo - If No, suggest they dial 911.

Relationship to the minor -select-LEOMotherFatherStep-motherStep-fatherGrandparentCaregiverTeacherSchool CounselorPrincipal/Head MasterSocial WorkerNeighbor

Student's name

Gender -select-FemaleMaleTransgenderGender non-conformingGender fluidNon-binary OtherRather not say

Age -select-12345678910111213141516171819+

Grade level -select-K123456789101112College

School District and School Name

Situational Details

Concerns FOMOLow self-confidenceMean studentsCyber-bullyingTech/gaming dependenceOther (See comments)

Red Flags Depressive behaviorsSelf-harmRun away riskRun awayMinor is receiving mental health servicesOther (see comments)

Digital and social media Details.

Does the child have their own Smart Phone? -Select-YesNoThey share one

Does the child have their own iTouch, iPad or tablet. -Select-YesNoThey share one

How many electronic devices are in the home? -select-123456+

Minor's social media usernames:

Snapchat

Instagram

TikTok

Facebook

Sinsta/Finsta/Spam Accounts

Do they have an account for collecting money?

Venmo / Paypal / Amazon

Intake notes.

Follow up Send emailPhone callIn-person meetingZoom meeting

Meeting Date and Time

Final thoughts

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