NOTE: It is best to complete this form using either a laptop or desktop using the Chrome Web Browser. Should you run into issues, please clear your browser cache.
Please complete all information on this form and bring it to your first visit. It may seem long, but most of the questions require only a check, so it will go quickly. You may need to ask family members about the family history.
You may need to ask family members
Indicate if you have ever taken any of the following medications.
Provide your details.
Provide phone numbers where we may contact or leave a message.
Main person to contact
Second contact
In case of an emergency, if the above two contacts cannot be reached.
The person responsible for the child's therapy service or financial agreement.
Details about the child's family.
A copy of court documents is required and will be a part of the child's file.
List all children and adults who live in the child's home. Add a new line for each member.Please include: name, age, sex, and relationship to child. Example: Bob, age 6, male, younger brother.Jane, age 15, female, older sister.
Please provide child's medical history as known.
Details about school(s) and learning skills.
Below is a list of concerns or problems, please check all that you feel applies to your child.
Birth, Infancy, and Early Childhood Development History
Please provide details.
Please check all of the behaviors that best describe your child during infancy and early childhood.
Please check all of the experiences that fit for your child during infancy and childhood.
Child’s Temperament, Traits, and Social Interactions.
Please check all that apply to your child.
Has your child or any of your family members struggled with any of the following?Check all that apply.
Sources and time your child spends on social media.
Please review your answers and sign this form to indicate you have answered questions to the best of your ability.
I have read and agree to the Terms and Conditions
Couples Counseling Initial Intake
Please note that you will be asked to talk about your answers in sessions, but your partner will not be shown this form.
For Therapy and Empowerment
Personal and Spiritual Background
Current Spiritual Practices
Spiritual Challenges and Growth
Therapeutic Goals and Empowerment
Additional Information
Please select your answers by clicking on the circle.
Please review carefully.
Please answer the questions below, rating yourself by selecting the best option that describes how you felt and conducted yourself over the past 6 months.Click on the word option as your answer.
Client Consent to Allow Personal Health Information (PHI) by Email or Text Message
Of patient/client information
Name of Patient or Authorized Representative
Certain information is covered by additional protection and requires specific authorization. To authorize release or discussion of the following type of information, the person named above must initial and date each item. If an item is not initialed and dated, the information, if such information exists, cannot be released or discussed.Select information types that apply and specify the date range of additional authorization release period.
The above-named person has the following rights:
This authorization is effective for the above requested and authorized health care information only. You may ask for and receive a copy of this authorization form.
This authorization will expire on the date you indicated above. Additionally, you may revoke this authorization at any time by submitting a written request to this clinic or caretaker. Your revocation will be honored except to the extent that is been acted upon in good faith while in force.
You have the right to inspect the information you are authorizing to be re-released. This and other specific rights regarding the handling of your health information are outlined in our Privacy Practices document.
The information you are authorizing to be released could be re-released or disclosed by the recipient. Such additional disclosures or releases may not be prohibited by law. We are not responsible for the actions of others who may be provided with information released as a result of this authorization.
You may refuse to sign this authorization. Such refusal will not affect your ability to obtain treatment except to the extent that the information being requested may assist your health care provider in determining appropriate treatment. Your refusal to sign this authorization will not affect your eligibility for benefits.
Good Faith Estimate for Services
I have read and agree to the Client Consent to Allow PHI by Email or Text Messages.
