CKHC Mental Health Intake Form

Mental Health Services Intake Form

Coastal Kids Home Care
Date

MonthDayYear
Date
Services for:
Service Requested
Grief/Bereavement Support (18+)
  *
1:1 Counseling (ages 5-21)*
Client Information
Client Name

First NameLast Name
DOB

MonthDayYear
Date
Name of referring person

First NameLast Name
Relationship to client
Client Insurance Type
Client Member ID
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Treatment History
Have you ever received therapy
Type of Therapy received
Provider/Organization name
Diagnosis given (If applicable)
Did you receive medication related to treatment
Has the client ever needed to be hospitalized due to mental health reason.
Has the client had any Suicidal ideation
If yes, please explain
Stressful Life Events
Stressful life events that have affected the client and/or family
Symptoms/Behaviors
Reason you are seeking services for your child.
Should be Empty:

Mental Health Services Intake Form