Please provide the following information below needed for our records.  All information will be held confidential in your client file. If there are questions that you do not wish to answer at this time, feel free to leave them blank.  Please complete the form prior to your first appointment.

This form needs to be fill out for both, adolescent and parent.

The first box about email please fill out with parent  email.

Adolescent please fill out Adolescent Section.  

Parent/guardian please fill out Parent/Guardian Section and Sections 5 and 6.