Child Intake Form

Please complete and submit this form prior to your first session.

Name of Client

Legal Name

First Name

Last Name

Preferred Name

If Applicable

First Name

Last Name

Client Date of Birth

MM

DD

YYYY

Age

Gender

Client Email

Client Phone

(###)

###

####

Client Primary Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name of Parent/Guardian

First Name

Last Name

Parent/Guardian #1 Phone

(###)

###

####

Parent/Guardian #1 Email

Name of Second Parent/Guardian

First Name

Last Name

Parent/Guardian #2 Phone

(###)

###

####

Parent/Guardian #2 Email

Who is the primary contact?

Parent/Guardian 1

Parent/Guardian 2