Parent Intake Forms

Parent Intake Form
Hello Parent! Thank you for entrusting the care of your young person to NY Therapy Space. In order to ensure the best care possible, please help me get to know all about your teen/tween by completing the following forms and giving some historical content.
Client Information
Adolescent's Full Name*

First NameLast Name
Preferred Name/Nicknames*
Date of Birth*

MonthDayYear
Date
Age*
Preferred Pronouns*
Gender Identity*
Sexual Orientation*
Race/Ethnicity*
Religion/Spirituality*
School*
Grade Level*
Accommodations*

NoneELL/MLL504IEPSETTSTransfer SchoolOther
Primary Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please list anyone who lives in your home with you*

Parent Intake Form