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New Client Intake (14+)
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* Indicates required question
Full Name of parent or Guardian
*
Your answer
Full Name of minor
*
Your answer
Minors Date of Birth
*
MM
/
DD
/
YYYY
Address
Your answer
Best contact number
Your answer
What is a good email address for you?
Your answer
Emergency Contact Person - Name and Phone
*
Your answer
What is your health insurance provider? Please include the ID#
Your answer
Are you currently under the care of a medical Physician?
*
Yes
No
Required
Are you currently under the care of a mental health professional?
*
Yes
No
Required
If yes, please provide Primary Care provider or Psychiatrist's information.
*
Your answer
Is your currently taking any medications and/or supplements? If yes, please describe.
Your answer
Does your child have any allergies?
*
Yes
No
Required
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