Client Intake Form
H&S Therapeutic Services
Today's Date:
*
-
Month
-
Day
Year
Date
How did they hear about us?
*
Referring Person:
First Name
Last Name
Referring Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Referring Email Address:
example@example.com
Relationship to Client:
*
Parent
Care Manager
Legal Medical Guardian
Other
Parent OR Legal Medical Guardian:
*
First Name
Last Name
Parent OR Legal Medical Guardian's Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Client Information
Full Name:
*
First Name
Last Name
Gender:
*
Please Select
Male
Female
Nonbinary
Date of Birth:
*
-
Month
-
Day
Year
Date
Phone Number:
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Home Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Type of Care Required:
*
After School Program
Individual Therapy
Group Therapy
CLS & Respite
Clinical Assessments
Other
Social Security #:
*
Medicaid ID:
*
Primary Physician Name:
*
Is your child verbal or non-verbal?
*
Please Select
Yes
No
N/A
Has your child received a diagnosis?
*
Yes
No
If yes, please state the diagnosis and what date it was given:
Any additional information/comments:
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Submit
Should be Empty: