Coastal Kids Home Care Counseling
Counseling Intake
A parent or legal guardian must approve the counseling services of the client before the intake process. This form is HIPAA compliant and ensures confidentiality.
Type of counseling needed
Kid/Teen Mild to Moderate Counseling
Kid's Group (Ages 7-10)
Support after Homicide, Suicide, and Accidental Death for Teens (Ages 12-18)
Client's Name:
First Name
Last Name
Parent's/Legal Guardian's Name:
First Name
Last Name
Parent's/Legal Guardian's Phone Number:
Please enter a valid phone number.
Parent's/Legal Guardian's Email:
example@example.com
Referred By:
First Name
Last Name
Reason for Referral:
Any additional/relevant information
Submit
Should be Empty: