Child/Teen/Young Adult Intake Form
For Parents/Guardians to Complete on Behalf of Their Child

Please fill out the following form to the best of your ability. There is a great deal of information requested. Do not be concerned if you do not remember, or do not have access to, all of it; do the best you can. If the question does not apply, enter N/A in the response window.

________________________________________________________________

* Required fields
Name *
E-mail Address *
Child's Name *
Child's Date of Birth *
Child's Age *
Sex *
List all household members, their age, and their relationship to the child. *
Guardian's Name, if other than parents
Unnamed
Parents Marital Status *
Is this child your *
This child lives with *
Custody Arrangements *
Address: Street *
City *
State *
Zip Code *
Home Phone *
Mother's Cell Phone *
Father's Cell Phone Number *
Guardian's Cell Phone Number
Child's Cell Phone
Child's Height and Weight *
Name & Adress of Child's School if currently enrolled
If child is not currently attending school, please explain why.
If the child is a young adult, not in school, and not employed, please explain why.
If your child is employed, name employer, describe your child's position, and how many hours worked a week.
Please provide a brief summary of your concerns regarding this child. *
Mother's Name
What are your hopes and expectations for the coaching process? *
My child has seen the following professionals regarding these same concerns. *
Please list all diagnoses your child has been given, by whom, and date. (month & year) *
Please provide a time line of all medications tried for all mental health diagnoses. To the best of your ability, give dose (mg.) & frequency. If no medication was tried, enter N/A. *
Please select your preferred appointment time option. Please note, all times listed refer to EST. *
Please select your second time choice for your appointment . Please note all times refer to EST. *


Please enter the code shown above and click the 'Submit Form' button. This additional step is required to help protect against message spam.