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Family Solace House Intake Form
*This form should only be filled out by the interested party
Please fill out to indicate interest in services. A staff member will contact you within three business days.
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Parent/Guardian's Name
*
Your answer
What service modality are you interested in
*
Choose
Individual Sessions - Grief Related
Individual Sessions - Trauma Related
Group Sessions
Family Sessions - Grief or Trauma Related
Both Individual and Group Sessions
Referrals
Not Sure
Parent/Guardian's Date of Birth
MM
/
DD
/
YYYY
Parent/Guardian's Race/Ethnicity
Your answer
Home Address
Your answer
County (zipcode)
*
Your answer
Best contact number
*
Your answer
Email
*
Your answer
Child 1 Name
*
Your answer
Child 1 Birthdate
*
MM
/
DD
/
YYYY
Child 1 Grade
*
Your answer
Child 1 Ethnicity
*
Your answer
Child 1 Gender Identity
*
Your answer
Please check any of these that apply for Child 1
nervousness/anxiety
feelings of hopelessness
mood swings
thoughts of suicide
behavior issues
poor impulse control
difficulty managing anger
attempts at suicide
thoughts of harming others
difficulty in concentration or memory
panic attacks
changes in appetite or weight
depressed mood
racing thoughts
frequent feelings of guilt
seeing things other people don't
cutting/hurting self
problems responding to discipline
history of physical/sexual abuse
bed wetting
financial stress
difficulty at work
family stress
history of drug and alcohol use
legal issues
Child 2 Name
Your answer
Child 2 Birthdate
MM
/
DD
/
YYYY
Child 2 Grade
Your answer
Child 2 Ethnicity
Your answer
Child 2 Gender Identity
Your answer
Please check any of these that apply for Child 2
nervousness/anxiety
feelings of hopelessness
mood swings
thoughts of suicide
behavior issues
poor impulse control
difficulty managing anger
attempts at suicide
thoughts of harming others
difficulty in concentration or memory
panic attacks
changes in appetite or weight
depressed mood
racing thoughts
frequent feelings of guilt
seeing things other people don't
cutting/hurting self
problems responding to discipline
history of physical/sexual abuse
bed wetting
financial stress
difficulty at work
family stress
history of drug and alcohol use
legal issues
Child 3 Name
Your answer
Child 3 Birthdate
MM
/
DD
/
YYYY
Child 3 Grade
Your answer
Child 3 Gender Identity
Your answer
Child 3 Ethnicity
Your answer
Please check any of these that apply for Child 3
nervousness/anxiety
feelings of hopelessness
mood swings
thoughts of suicide
behavior issues
poor impulse control
difficulty managing anger
attempts at suicide
thoughts of harming others
difficulty in concentration or memory
panic attacks
changes in appetite or weight
depressed mood
racing thoughts
frequent feelings of guilt
seeing things other people don't
cutting/hurting self
problems responding to discipline
history of physical/sexual abuse
bed wetting
financial stress
difficulty at work
family stress
history of drug and alcohol use
legal issues
Child 4 Name
Your answer
Child 4 Birthdate
MM
/
DD
/
YYYY
Child 4 Grade
Your answer
Child 4 Gender Identity
Your answer
Child 4 Ethnicity
Your answer
Please check any of these that apply for Child 4
nervousness/anxiety
feelings of hopelessness
mood swings
thoughts of suicide
behavior issues
poor impulse control
difficulty managing anger
attempts at suicide
thoughts of harming others
difficulty in concentration or memory
panic attacks
changes in appetite or weight
depressed mood
racing thoughts
frequent feelings of guilt
seeing things other people don't
cutting/hurting self
problems responding to discipline
history of physical/sexual abuse
bed wetting
financial stress
difficulty at work
family stress
history of drug and alcohol use
legal issues
Were you served by Kansas City Hospice in the last year?
*
Yes
No
Other:
Do you have insurance?
Yes
No
Other:
Clear selection
If yes to insurance, what carrier?
Your answer
If yes to insurance, what carrier?
Your answer
Social Security Number (for insurance purposes if applicable)
Your answer
List other family members in the household: Name, Age, and Gender Identity
Your answer
What is your combined household income? (for grant/sliding scale purposes)
Your answer
Does your child(ren) qualify for free or reduced lunch?
Choose
Yes
No
Briefly describe why you are seeking our services
*
Your answer
If you are seeking services for grief what is the cause of death?
Choose
Illness
Accident
Substance Use/Overdose
Suicide
Homicide
Unknown
Name of the Deceased 1 (if applicable)
Your answer
Date of Death 1 (if applicable)
MM
/
DD
/
YYYY
Name of the Deceased 2 (if applicable)
Your answer
Date of Death 2 (if applicable)
MM
/
DD
/
YYYY
What are your strengths?
Your answer
Describe your support system
Your answer
Have you ever had inpatient or outpatient treatment for emotional or mental health concerns in the past?
Yes
No
Other:
Clear selection
List any medical or physical issues you would like your therapist to be aware of.
Your answer
Do you have a regular medical provider?
Yes
No
Other:
Clear selection
List any prescription and over the counter drugs and supplements you use.
Your answer
Please add anything important that you want your therapist to know (i.e. past or recent trauma, gender identity, your pronouns, sexual orientation, multiple losses, cultural identity information)
Your answer
How did you hear about us?
*
Your answer
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