Child & Adolescent Intake Form
Please note: Missing information may delay the referral process
Name:
*
First Name
Last Name
Sex:
*
Gender:
*
Preferred Pronouns:
*
Current Age:
*
Date of Birth:
*
-
Month
-
Day
Year
Date
School:
*
Grade:
*
Pediatrician:
*
First Name
Last Name
Caretakers:
*
Married
Separated
Divorced
Unmarried
Legal Responsibility:
*
Caretaker #1:
*
First Name
Last Name
Caretaker #1:
*
Natural
Adoptive
Foster
Step
Caretaker #1:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caretaker #1 Tel. (C):
Please enter a valid phone number.
Caretaker #1 Tel. (H):
Please enter a valid phone number.
Caretaker #1 Tel. (W):
Please enter a valid phone number.
Email:
example@example.com
Preferred Method of Contact:
*
Cell
Home
Work
Email
Back
Next
Caretaker #2:
First Name
Last Name
Caretaker #2:
Natural
Adoptive
Foster
Step
Caretaker #2:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Caretaker #2 Tel. (C):
Please enter a valid phone number.
Caretaker #2 Tel. (H):
Please enter a valid phone number.
Caretaker #2 Tel. (W):
Please enter a valid phone number.
Email:
example@example.com
Preferred Method of Contact
Cell
Home
Work
Email
To Make an Appointment, Contact:
*
First Name
Last Name
Phone Number:
*
Please enter a valid phone number.
Email:
*
example@example.com
Referred By:
First Name
Last Name
Role:
Current Medication (if applicable):
Current Diagnosis (if applicable):
Reason for Referral (please be specific):
*
Back
Next
Insurance:
*
Policy ID #:
*
Group #:
*
Employer:
*
Subscriber:
*
Phone Number:
Please enter a valid phone number.
Secondary Insurance:
Policy ID #:
Group #:
Employer:
Subscriber:
Social Security # (required for Medicare):
Is there a particular therapist you are looking to work with? If so, please list the name(s) of the therapist(s) below:
Do you have a preference of in person or Telehealth therapy sessions?
*
In person
Telehealth
No preference
Desired frequency of sessions?
Weekly
Bi-weekly
Other
Do you have a preference of a male, female or non-binary therapist?
*
Male
Female
Non-binary
No preference
What is your availability? Please list days and times:
*
Is there anything else you would like us to know?
Submit
Should be Empty: