Child & Adolescent Intake Form

Child & Adolescent Intake Form

To be completed by the child's parent/ guardian
Child's Legal Name

First NameLast Name
Today's Date

MonthDayYear
Date
Child's Age
Date of Birth
Grade Level
Parent/ Guardian Legal Name

First NameLast Name
Parent/ Guardian Relationship to client:
Parent/ Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
May we leave a voicemail?
Parent/Guardian Email Address (email is non-secure)
example@example.com
Paren/ Guardian Occupation & Employer
Annual Income (for sliding scale purposes if needed).
Emergancy Contact

First NameLast Name
Emergency Contact Relationship to client
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Client Address

Street Address

City, State, Zip

EmailPhone Number

Postal / Zip Code
Who were you referred by:
Household Composition - Primary Residence (list name, age, and relationship of all living here).
Household Composition - Secondary Residency (if any). Please (list name, age, and relationship of all living here.
Parent's Marital Status
Date of separation, divorced, widowed, or remarried
Adoption Status
List of Child's Siblings names and ages (if different from household composition):

Childs' Medical History