Parent Intake Basic InformationName of Mother First Last Name of Father First Last Name of Child seeking treatment* First Last Age of Child seeking treatment Please List Name/Age of all SiblingsPlease list school & grade of child seeking treatment Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone MotherPhone FatherEmail Mother Email Father Child History & InfoHas child used substances* Yes No this is a current concern past occurrence, not immediate concern child has received previous treatment for this issue Uncertain If yes, please list substances and last date of useIs there a history of suicide ideation/attempt* Yes No this is a current concern this is a past occurrence, but not immediate concern child has received previous treatment for this issue uncertain Is there a history of eating disorder* Yes No this is a current concern this is a past occurrence, but not immediate concern child has received previous treatment for this issue uncertain Is there history of cutting or other self inflicting harm behaviors* Yes No this is a current concern this is a past occurrence, but not immediate concern child has received previous treatment for this issue Uncertain Is child sexually active? Yes No Uncertain Is there history of sexual abuse/trauma* Yes No this is a current concern this is past occurrence, but not immediate concern child has received previous treatment for this issue Uncertain Have you noticed shifts/changes in the last 6 months in any of the following areas* academic performance peer relationships family relationships recreational activities substance use/abuse Uncertain If yes to any of above, please briefly explainPayment Consent & InformationI have read, understand & authorize the following payment policies (checking the boxes below indicates approval response "yes"):* Credit card will be held on file and charged accordingly on dates of service Late cancellations (less than 24 hours) will yield a full fee payment for hour I will be charged full payment for “no show” sessions I authorize payments for services, late cancellations and no show fees accordingly Credit Card Information – this is a HIPPA compliant secure site*Please include: 1. credit card number 2. expiration date 3. CVV 4. Zip CodeParent InsightMother: Please briefly list any additional concerns regarding child's behavior or historyMother: Please identify goals for therapy in regards to this childFather: Please briefly list any additional concerns regarding child's behavior, historyFather: Please identify goals for therapy in regards to this childCAPTCHAEmailThis field is for validation purposes and should be left unchanged.
