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Adolescent Intake Form

Ages 12-17

Client Contact Information

Birthday
Month
Day
Year
Sex at Birth

This is solely for the purpose of billing your insurance company.

Multi-line address

Guardian Information

Insurance Information

Insurance Type

If self-pay, please enter N/A

If self-pay, please enter N/A.

Policy Holder's Date of Birth
Month
Day
Year

If self-pay, please enter client's date of birth.

Do you have secondary insurance?
Yes
No

If you have a secondary insurance policy and fail to supply that information, you may be held responsible for the full balance of sessions.

Secondary Insurance Type
Secondary Insurance Policy Holder's Date of Birth
Month
Day
Year

Therapy Questionaire

Are you currently in therapy?
Yes
No
Have you been in therapy before?
Yes
No
Most Recent Time in Therapy
Month
Day
Year
Have you had any previous hospitalizations for mental health or substance use concerns?
Yes
No
Are you currently taking psychiatric medications for:
Are you currently facing legal action(s)?
Yes
No
If you would like to request a specific counselor, please indicate below.

© 2025 by Resolutions Counseling, Inc.

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