Child & Adolescent Intake Form (Otter Creek)

Child & Adolescent Intake Form
Personal Information
Referred To: *Please note - Psychiatry may be limited, if available.
Location
Legal Last Name
Legal First Name
Preferred Name and Pronouns:
School
Grade
Pediatrician
Parents/ Guardians
Legal Custody
Physical Custody
Mother
Mother
Father
Parent 2
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Ok for Message?
E-mail
Birth Date

MonthDayYear
Current age:
Gender on record if using health insurance:
Referred By:
PCP:
Location
To Make an Appointment Contact
Phone Number

Area CodePhone Number
Current Medication
Current Diagnosis (if applicable)
Reason For Referral (please be specific, as this will help us match you with an appropriate provider)
Insurance/Billing Information
Insurance
Phone
Policy ID
Group Number
Employer
Secondary Insurance
Subscriber
SSN
Do you have a preference of in person or telehealth sessions?
Do you have a preference of a male, female or non-binary provider?
What is your availability? Please list both days and times.
Enter the message as it's shown
Should be Empty:

Child & Adolescent Intake Form