Child/Teen/Young Adult Intake Form

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. *	Pediatrician General Practioner Pediatric Psychiatrist Neurologist School Psychologist School Counselor Private Therapist Chiropractor Tutor Educational Specialist Physical Therapist
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. *

I have read and agree to the Privacy Policy *

Spam prevention

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

Enter code above: