Child Information Form

Child Information Form

Complete this intake using the child’s perspective, then add parent perspective where requested.
If a parent is completing this form, please include child's perspective.
Child's Full Name
Full Name
Date of Birth

MonthDayYear
Date

Primary Household

Parents

Rows	Name	Relationship	Occupation
Parent 1
Parent 2

Children
Secondary Household
Secondary household not applicable

Parents

Rows	Name	Relationship	Occupation
Parent 1
Parent 2

Children
What are the custody and visitation arrangements?
Note: In situations with divorce we need a copy of the custody arrangements.

Patient Insight
*Please include parent perspective
Please describe why you are here
What would you like to accomplish from counseling?
What would you like to see changed in your family?
Client Signature (if applicable)
Signature
Date

MonthDayYear
Date
Should be Empty: