Child/Adolescent Counseling Intake Form

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Child/Adolescent Counseling Intake Form

Please take a moment to thoughtfully respond to the following questions in this form. Your answers will provide a foundation on which we will build a treatment plan for your child. Any detailed information you can provide is helpful.

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Parent/s Name/s

Your answer

Parent Phone Number

Your answer

Parent Email Address

Your answer

Child's Name

Your answer

Age

Your answer

Grade (teacher if needed)

Your answer

Reason for referral and who referred you?

Your answer

Please describe your concerns about this child?

Your answer

What do you hope to get out of therapy?

Your answer

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