Free Youth Mental Health Counseling
This form serves as the initial intake to gather basic information from youth and families interested in our free counseling services. Priority will be given to youth ages 8–24 who are uninsured or covered by Medicaid.
Section 1: Basic Information
Youth Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Gender Identity
*
Male
Female
Non-binary
Prefer not to say
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Race/Ethnicity
*
Black/African American
Hispanic/Latino
White
Asian
Native American
Other
School Name & Grade
*
Is the youth currently enrolled in Medicaid, CHIP, or uninsured?
*
Medicaid
CHIP
Private Insurance
Uninsured
Section 2: Parent/Guardian Contact Info
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Youth
*
Phone Number
*
-
Area Code
Phone Number
Email Address
*
example@example.com
Preferred Language for Communication
*
English
Spanish
Other
Section 3: Presenting Concerns
What brings you or your child to counseling?
Has your child experienced any of the following?
*
Grief/Loss
Bullying
Trauma or Violence
Anxiety
Depression
Suicidal Thoughts
Behavioral Issues at School
Other
Have they received counseling before?
Yes
No
If yes, please describe briefly.
Signature
Section 5: Screening Authorization (Optional but Encouraged)
We offer brief screenings to better understand emotional needs (GAD-7, PHQ-9).
Do you authorize us to complete brief wellness screenings with your child?
Yes
No
Would you like to receive follow-up information or referrals?
Yes
No
Section 6: How Did You Hear About Us?
Community Event
School
Social Media
Friend or Family
CHAMP Mobile Mental Wellness Unit
Other
Submit & Begin the Healing Journey
Should be Empty: