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Parent & Child Intake Form

Section 1: Child Information

Child's Full Name*

Date of birth*

Month

Day

Year

Child's Age*

Address*

Phone Number

Section 2: Parent/Guardian Information

Parent/Guardian First name

Parent/Guardian Last name

Relationship to child*

Phone*

Email*

Preferred Contact Method*

Phone

Text

Section 3: Emergency Contact

Name*

Phone Number*

Relationship*

Section 4: Insurance Details

Insurance Provider*

Policy Number*

Group Number

Authorization for services

Section 5: Medical & Behavioral History

Primary Physician

Phone Number

Current Diagnoses:*

Medications*

Allergies*

Previous Therapy or Counseling:*

Yes

If yes, please describe:

Section 6: Presenting Concerns

Main concerns or reasons for seeking treatment*

When did these concerns begin?*

What strategies have been tried so far?*

Section 7: Behavioral & Emotional Information

Current Behaviors of Concern*

Triggers or Stressors*

Preferred Reinforcers or Motivators*

Section 8: Child’s Preferences

Favorite Activities

Comfort Items

Preferred Communication Style

Things That Help Calm the Child

Section 9: Goals for Treatment

Primary goals for your child’s treatment or counseling*

Section 10: HIPAA Compliance & Consent

I acknowledge that all personal health information will be kept confidential in compliance with HIPAA regulations. I consent to the use and disclosure of my information for treatment, payment, and healthcare operations as outlined in the privacy policy.

Section 11: Media Release

I grant permission for photographs, videos, or audio recordings of my child to be taken during sessions for the following purposes (check all that apply):

Clinical Documentation

Training and Education

Marketing/Promotional Materials

Social Media (with confidentiality maintained)

Parent/Guardian Signature*

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First Name

Last Name

Phone

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Visit Us

2021 S Jones Blvd., Suite 110

Las Vegas, NV 89146

info@careprojectlv.org

Call Us

Main: (702) 779-3626

Fax: (702) 779-3724

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