DLS Counseling: Child intake

* First Name

* Last Name

* Date of Birth

* Age

* Street Address

Address Line 2

* City

* State

* Zip Code

* Phone Number

* Email Address

* School Atending

* Grade

* In case of emergency, contact:

* Phone number:

Family Information

* Child's parents are:

Married

Divorced

Separated

Widowed

* Father's Name

* Mother's name

* Father's Cell Phone

* Mother's Cell

* Father's email

* Mother's email

Siblings:

age

* What is the reason you are seaking help for your child?

* What would you like to see happen as a result of therapy?

* Child's Physician

* Date of last physical

Any current Medications:

* Has your child received therapy or counseling in the past?

If Yes, What was the date:

Who was the therapist?

* Is there a family history of any of the following:

	Father's Side	Mother's Side
	Yes	No
Alcohol Abuse
Drub Abuse
Anxiety
Phobias
Obsessive/Compulsive Disorder
Depression
Learning Delays
Suicide/Suicidal thoughts

Is there any other information you would find helpful in sharing with us today?

* Indicates Response Required