Child/Adolescent Intake Form

First name

Last name

Child's date of birth

Month

Day

Year

Pronouns

Please list grade and school of attendance

Please list any school supports

Has your child ever had therapy before? If yes, with whom?

Parent/Guardian 1

Parent/guardian name

Occupation

Parent/guardian home address

Parent/guardian phone

Parent/guardian email

Parent/Guardian 2

Parent/guardian name

Occupation

Parent/guardian home address

Parent/guardian phone

Parent/guardian email

Child/Adolescent

Please list any siblings and ages

Are there any custody orders in place?

Yes

No

If "yes," do you have a copy of the current custody order?

Are you interested in

Therapy

Assessment

Briefly describe your concerns

Please list any prescribed medication, supplements, or over-the-counter medication

Does your child present with any dietary or feeding concerns?

Yes

No

If "yes," please list your concerns

Any access to weapons in the home?

Yes

No

History

Any prenatal difficulty?

Yes

No

If "yes," please list any prenatal difficulty

Any delays in development?

Yes

No

If "yes," please list any delays

Insurance

Would you like to see if we can bill your insurance?

Yes

No

While we will do our best to bill your insurance, it is your responsibility to contact your insurance company for information regarding any deductibles or copays. If we cannot bill your insurance or your session fees go to your deductible, you will be responsible for the cost of service at the time of the appointment.

Please make sure you inform us of any secondary coverage prior to your first appointment.

Superbills for the cost of service can be provided following payment for each session.

Upload the front and back of your insurance card here. We will contact your insurance company to verify your coverage.

Thank you for completing this form. We will reach out to you within 48 hours to discuss scheduling!