Client Child Intake Form

CLIENT CHILD INTAKE FORM

Identifying Information

Date of Birth:    Age:    Gender:

Home Phone:    Cell Phone:    Email:

Parent / Legal Guardian Information

Relationship to Child:    Employer:

Work Phone:    Alternate Phone:

Relationship to Child:    Phone:

Emergency Contacts & Authorized Pick-Up

Phone:    Alternate Phone:

Medical / Health Information

Developmental, Social & Behavioral History

Has the child seen a mental health professional before?   Yes   No

Risk concerns (check all that apply):   Suicidal ideation   Self-harm   Aggression / violence

Educational / Special Services

Does the child have an IEP or 504 plan?   Yes   No

Insurance & Billing

Policy / ID Number:    Group Number:    Subscriber Name:

By signing below, the responsible party acknowledges financial responsibility for charges not covered by insurance, as set forth in the provider's billing policies, including cancellation and no-show fees. The provider may bill the insurance carrier as authorized by the responsible party.

Consent, Confidentiality & Authorizations

Consent to Treatment: I, as parent or legal guardian, hereby authorize and consent to assessment and therapeutic services for the child named in this form. I understand that services may include interviews, behavioral observation, counseling, parent guidance, and coordination with other professionals where necessary for treatment. I understand that I may withdraw consent in writing at any time, subject to obligations to pay for services already provided.

Limits of Confidentiality: I acknowledge that some information shared may be disclosed without consent where required or permitted by law, including suspected child abuse or neglect, threats of serious harm to self or others, or court-ordered disclosures. Provider will make reasonable efforts to obtain authorization before releasing other confidential information.

Release of Information: I authorize the provider to share treatment information with other professionals, agencies, schools, or insurance carriers when necessary for coordination of care and payment, only as expressly indicated below or as otherwise permitted by law. I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on it.

Telehealth/Remote Services Consent: I consent to the use of telehealth or remote communications for delivery of services when appropriate, understanding additional limitations to confidentiality and technology-related risks. I may decline telehealth and request in-person services when available.

Photography / Recording: I authorize the provider to use clinical photographs or recordings for treatment documentation only. Use for training or publication will require separate written authorization unless de-identified.

Cancellation Policy: Appointments canceled less than 24 hours in advance or missed without notice may be subject to a cancellation fee. Emergency exceptions will be considered at the provider's discretion.

I consent to treatment and have read and understand the statements above.

I authorize release of records as described above and accept financial responsibility as stated.

Presenting Issues & Goals

Legal / Custody Information

Is there a custody or guardianship order affecting access to the child?   Yes   No

Acknowledgment & Certification

I certify that the information provided in this intake form is true and complete to the best of my knowledge. I will notify the provider of any significant changes in medical status, living situation, or legal custody. I understand that falsification of information may affect eligibility for services and could result in termination of services.

Sign Now