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Client Information Form
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* Indicates required question
Parent's Name
*
Your answer
Email address
*
Your answer
Best Phone Number
*
Your answer
Address:
*
Your answer
Child's First and Last Name
*
Your answer
Date of Birth of Child
*
MM
/
DD
/
YYYY
My Child is struggling with:
*
Your answer
Marital Status - This information is needed to know if we would have to send a "parent consent form for the other parent to sign or if further documentation is needed"
*
Married and Together
Separated/Divorced - We will send a parent consent form
Separated/Divorced but have sole legal custody - Copy of the custody agreement needed
Other:
Parent Intake session is the initial session. Would you like it to be
*
Virtual
In-Person
Virtual or In-Person
Do you have any access requirements?
*
Yes
No
If you answered "Yes" to the above question, please explain.
Your answer
We are out of network for all insurances, do you plan to submit an insurance claim for reimbursement
*
Yes
No
Tricare - Do you have Tricare Insurance?
*
Yes
No
How did you hear about us or who were you referred by?
*
Your answer
Electronic Signature - Please Type Name
*
Your answer
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