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Child/Adolescent Intake Form
Thank you for reaching out to our office for support in your journey toward brighter days. We are honored to walk with you and your family.
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* Indicates required question
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Email address (parent and/or child/adolescent)
*
Your answer
Email address (parent and/or child/adolescent)
Your answer
Address
*
Your answer
City, State, Zip
*
Your answer
Phone 1
*
Your answer
Phone 2
Your answer
How did you hear about Brave Tomorrow?
Your answer
Emergency Contact
*
Your answer
Emergency Contact Phone
*
Your answer
Emergency Contact - relationship to client?
*
Your answer
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