Child Intake Form

General

Child's first/middle/last name *

Birth date *

Month

Day

Year

Child's age

Legal guardian and relationship with child *

Are the parents separated or divorced? *

Person(s) or agency posessing custody of child *

Home address *

City *

State *

Zip *

Home phone *

Cell phone

Emergency Contact Name and Phone Number *

Was your child adopted? *

Does the other parent know about you seeking behavioral health services for your child? *

Yes

If yes, has he/she consented to your child receiving such services? *

Yes

Note: Please bring all legal documentation and other evaluations prior to your first appointment.

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