2025-2026 Therapy Intake & Consent Form    Logo
  • Therapy Intake & Consent Form

  • ONLY COMPLETE THIS FORM IF YOU HAVE RECEIVED APPROVAL FROM YOUR STUDENT'S FAMILY SCHOOL LIAISON (FSL)

    Please complete all forms in its entirety. All information on this intake form is considered strictly confidential. 
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  • Developmental History

    This section will ask about the student's developmental history. Please provide as many details as possible.
  • Trauma History

    This section will ask about the student's trauma history. Please provide as many details as possible.
  • Family History & Interaction

    This section will ask about the student's family history and family interaction. Please provide as many details as possible.
  • Psychological/Mental Health History

    This section will ask about the student's mental health history. Please provide as many details as possible.
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