Multidisciplinary Enrollment Form

Welcome to Mala Child & Family Institute

We are glad you are here. This form helps our team guide you toward the right services, providers, and next steps. Whether you are new to Mala or already receiving care, this form helps us coordinate care thoughtfully and efficiently.
_{Emergency Disclaimer: If you or someone you know is experiencing a crisis or emergency, please call 911 or go to your nearest emergency room.}_{Mala Child & Family Institute does not provide emergency services.}
Relationship To Mala
Which of the following best describes you right now?

Who Is Seeking Support
Please complete a separate form for each individual client seeking services so we can create the correct enrollment pathway and care plan.
Who is seeking support?
Has anyone in your household previously received care at Mala?

Client Information
If the client is a teen and you would like them to receive appointment reminders directly, you may include the teen’s email address and phone number.
Legal Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Home Address

Street Address

Street Address Line 2
CityStateZip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Preferred Name
Pronouns

Parent/Guardian Information
Because children do best when their support system is coordinated, we require a second adult contact for all child clients. Please provide the contact information for the other legal parent. This is required for divorced or separated households.
Parent/Legal Guardian Name

First NameLast Name
Relationship to Client
Parent/Legal Guardian Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Legal Guardian Email
example@example.com
If parents are divorced or separated, the second contact must be the other legal parent if they share legal custody.

Mala does not manage payment arrangements between parents. Parents are responsible for managing payment agreements between themselves.
Secondary Adult Contact Name

First NameLast Name
Secondary Adult Contact Relationship
Secondary Adult Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Adult Contact Email
example@example.com
Are the child's parents divorced or separated?
Do both parents share legal custody?
Divorce or custody agreement

Cancelof

Adult Emergency Contact

We require an emergency contact for all adult clients to support safety and continuity of care.
Emergency Contact Name

First NameLast Name
Relationship
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Services of Interest - Psychotherapy

(e.g., play therapy, art therapy, relational counseling, individual therapy for youth or adults, parent coaching, executive function coaching)
Are you interested in psychotherapy/counseling services?

Insurance & Payment
We verify your benefits before you begin care with us.
Insurance Company Name/Payment Option

Other
Member ID / Subscriber ID
Group number
Name of Policy Holder
Primary Holder Date Of Birth

MonthDayYear
Date
Address of Policy Holder
Client Relationship to Policy Holder
We will asked you to provide a copy of your insurance card and driver's license later during enrollment and prior to the first appointment. We also require an active credit card on file.

Accessibility & Support Needs
Are there any sensory, communication, accessibility, cultural, language, trauma-related, or scheduling needs that would help us support you well?
Preferred method of communication

Consent to Contact

I consent to being contacted by Mala Child & Family Institute regarding services, scheduling, care coordination, and enrollment. I understand this does not establish a therapeutic relationship.
Should be Empty:

Welcome to Mala Child & Family Institute