Family Counseling Inquiry Form

Family Counseling Inquiry Form
Child's Name*

First NameLast Name
Gender

MaleFemale
Date of Birth*

MonthDayYear
AdoptedBiologicalFoster Care
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which describes you best?

MarriedMarried/Step-familySingle Parent/DivorcedSingle Parent/WidowedSingle Parent/Never MarriedLegal Guardian
Parent's Name*

First NameLast Name
First NameLast Name
Phone Number(s)
Email Address
Which counseling location do you prefer?

Loop Campus (7401 Katy Freeway Houston, TX 77024)Sienna Campus (4309 Sienna Parkway Missouri City, TX 77459)Cypress Campus (11011 Mason Road Cypress, TX 77433)
(Not all campuses have the same availability but we will try to match your needs to the best of our ability)
Church Affiliation
Sibling 1
Gender, Age/DOB, Adopted/Bio/Foste
Sibling 2
Gender, Age/DOB, Adopted/Bio/Foste
Sibling 3
Gender, Age/DOB, Adopted/Bio/Foste
Sibling 4
Gender, Age/DOB, Adopted/Bio/Foste
Brief Explanation of Concerns
Custody Verification Paperwork
If you are divorced from the biological parent of the child(ren) you are seeking therapy for, do you have a divorce decree or legal document that states who can consent to counseling?

YesNo
If you are the legal guardian of the child that counseling is being sought for, do you have legal documentation that states you can consent to therapy?

YesNo
*Please email prior to your session or bring a copy of your signed divorce decree/legal document regarding ability to consent to the counseling of a minor(s) to your Parent Intake session.
Should be Empty: