NEW INTAKE FORM
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Client's Name
*
First Name
Last Name
Client's DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Prefer not to answer
Other
Parent/Guardian/Authority Name:
*
First Name
Last Name
Parent/Guardian/Authority DOB
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Additional Information (If separated add both parent’s information):
(1) Parent/Guardian Name:
*
First Name
Last Name
Parent/Guardian DOB:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to client:
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
*
example@example.com
(2) Parent/Guardian Name:
First Name
Last Name
Parent/Guardian DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Relationship to client:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Emergency Contact [Must be someone other than Parent/Guardian]:
*
First Name
Last Name
Relationship to client:
*
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Please check on of the following options for race/ethnicity:
*
American Indian/Alaska Native
Hispanic/Latino
Multi-race
Asian
Hawaiian Native/Pacific Islander
White
Black/ African American
Middle Eastern/North African
Prefer not to answer
Other
Preferred Counseling Location:
*
Boise
Meridian
No preference
Reason for Visit. (Check all that apply):
*
Worry/Concern
Friendship issues/bullying/being bullied
Easily distracted
Depression
Grief
Lack of motivation
Suicidal ideation/suicidal attempts
Problems sleeping/eating concerns
Hyperactivity
Isolation
Gender or sexual identity
Anger/outburst
School refusal or problems at school
Relationship issues parent/child or child/friend
Other
Additional Comments/Concerns:
How did you hear about the Children's Home?
*
Family/Friend
Doctor/Counselor/Clinic
School
Former Client
Internet Search/Online Ad
Social Media
Parent Guide
Stroll Magazine
Drive-By
*
I agree to receive communications by text message from the Children’s Home Counseling Services about my inquiry. You may opt-out by replying STOP or ask for more information by replying HELP. Message frequency varies. Message and data rates may apply.
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Insurance Provider [Primary]:
*
Policy #:
*
Subscriber Name:
*
First Name
Last Name
Subscriber Name DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurance Provider [Secondary]
Policy #:
Subscriber Name:
First Name
Last Name
Subscriber Name DOB:
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
Submit
Should be Empty: