Phone

This field is for validation purposes and should be left unchanged.

Today's Date*

Intake Form

Please complete the following intake form. The more detailed you can be in completing this form, the more effective/efficient our first appointment can be.

Note: Red asterisks indicate required fields.

First / Last name*

Date Of Birth*

Age

Ethnicity

Gender*

Preferred Pronouns

SSN#*

Home Phone #*

Cell #

Work Phone #

Patient Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name(s) of patient’s legal guardian(s)*

Parents are

Are guardian(s) the biological parents*

Yes

No

If patient adopted, parents divorced, or otherwise notable, what are the custody arrangements? (Please bring copy of custody arrangement for the chart)

This form completed by (YOUR name)*

Relationship to the patient*

Age

Address (if different from the patient)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone # (if different from the patient)

Cell # (if different from the patient)

Work # (if different from the patient)

Email address

Highest Level of Education

Occupation

Place Employed

Please provided other parent/guardian’s information, including address and phone number (if different from the patient).

Name

Age

Home # (if different from the patient)

Address (if different from the patient)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email address

Highest Level of Education

Occupation

Place Employed

Does your child have any siblings?

Name

1 per line

Age

1 per line

Gender

1 per line

Where does child reside

1 per line

Additional Emergency Contact(s) (Name, relationship, and phone number)

1 per line

Patient’s Primary Care Physician or Health Care Provider:

Name

Title (MD/DO, APRN, etc.)

Phone #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Previous/Current Psychiatrist or other Mental Health Professional:

Name

Title (MD/DO, APRN, etc.)

Phone #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Other Professional:

Name

Title (MD/DO, APRN, etc.)

Phone #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Concerns and/or Reasons for Referral*

Current School

Current Grade

Ever been held back or repeated grade

Yes

No

Ever been suspended or expelled

Yes

No

Please Explain

Describe any problems brought to your attention by your child’s teachers

Any recent change in grades

Is child receiving special accommodations at school? If YES, please specify (IEP, 504 PLAN, etc.)

ADDITIONAL SOCIAL HISTORY

If child is adopted, how old was he/she when the adoption occurred

If child is adopted, do you have any information about the biological parents? Please specify

Was child ever removed from parental custody or placed in foster care? If YES, please explain

Are there any significant problems in the home? If YES, please specify

New Patient Packet

New Patient Packet