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Adolescent Intake Form

Ages 12-17

Client Contact Information

Client's First name*

Client's Last name*

Preferred Name

Age*

Birthday*

Sex at Birth*

Male

Female

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

Preferred Pronouns

Email*

Phone*

Country/Region*

Address*

City*

Zip / Postal code*

Guardian Information

Guardian's First Name*

Guardian's Last Name*

Relationship to Client*

Guardian's Phone*

Guardian's Email*

Insurance Information

Insurance Type*

Insurance ID*

If self-pay, please enter N/A

Policy Holder's Name*

If self-pay, please enter N/A.

Policy Holder's Date of Birth*

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 ID

Secondary Insurance Policy Holder's Name

Secondary Insurance Policy Holder's Date of Birth

Therapy Questionaire

Are you currently in therapy?*

Yes

No

Have you been in therapy before?*

Yes

No

Most Recent Time in Therapy

Have you had any previous hospitalizations for mental health or substance use concerns?*

Yes

No

If yes, please explain.

Are you currently taking psychiatric medications for:

Anxiety

Depression

Other

Please list your current medications:

Are you currently facing legal action(s)?*

Yes

No

If yes, please explain:

Please give us a brief description of your concerns and goals for therapy.*

If you would like to request a specific counselor, please indicate below.

How were you referred to us?*

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