Parent Counseling Intake Form
Please complete this intake form to help us understand your family’s needs and provide the best possible support.
Parent/Guardian Full Name
*
First Name
Last Name
Relationship to Child (e.g., mother, father, guardian)
*
Please Select
Mother
Father
Step-parent
Grandparent
Legal Guardian
Other
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Child’s Full Name
*
First Name
Last Name
Child’s Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Who lives in the household? (List names, ages, and relationship to child)
*
Primary reason(s) for seeking counseling
*
Behavioral concerns
Emotional issues (anxiety, depression, etc.)
Family conflict
School-related issues
Parenting support
Other
Please describe any previous counseling or therapy experiences for your child or family.
What are your main goals or expectations for counseling?
*
Is your child currently taking any medications? If yes, please list them.
Emergency Contact Name and Relationship
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Submit Intake Form
Should be Empty: