Intake Form

Parent/Legal Guardian

Home Number

Street Address, State, Zipcode

Cell Number

Child's Legal Name

Preferred Name/Nick Name

Child's Age

Childs Grade

Child's DOB

Childs Primary Insurance ID #

Childs Secondary Insurance Provider

Childs Secondary Insurance ID

How did you hear about us?

If yes, please tell us this diagnosis

Case Worker

CHILDREN'S BEHAVIORAL & MENTAL HEALTH SERVICES