Minor Intake - Resolutions Counseling, Inc

Please note that we are currently experiencing extended wait times for children ages 7-12. Once we receive your intake form, we will work to get your child scheduled with a therapist as quickly as possible or provide you with additional referrals for treatment if needed.

Client's Name(Required)

First Last

Date of Birth(Required)

Age(Required)

Please enter a number from 0 to 100.

Sex at Birth(Required)

Male

Female

Prefer not to say

This is for the purposes of billing your insurance company. If you prefer not to say or do not plan to use your insurance, please select “prefer not to say”.

Current Address(Required)

Street Address City State ZIP Code

Guardian Name:(Required)

First Last

Relationship to Client(Required)

What’s your relationship to the client?

Phone(Required)

Email(Required)

Would you like to use insurance or would you like to self-pay?(Required)

Insurance

Self-Pay

Please consider your selection carefully. Incorrect submissions can significantly slow your intake process

Insurance Company(Required)

Insurance ID(Required)

Policy Holder's Name(Required)

Policy Holder's (DOB)(Required)

Do you have secondary insurance?(Required)

Yes

No

Insurance Company(Required)

Insurance ID(Required)

Policy Holder's (DOB)(Required)

Currently in therapy?(Required)

Yes

No

Has the client been in therapy?(Required)

Yes

No

If yes, date of most recent therapy?

Any previous hospitalizations for mental health concerns?(Required)

Is the client currently on any medicaiton for:

Depression

Anxiety

Other mental health concerns

Check any that apply.

Are there any pending or recent legal issues regarding this client that might become a focus of care?(Required)

Please give a brief description of of the purpose in seeking therapy and goals for therapy:(Required)

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

How were you referred to us?

If you were referred by someone in the community (counselor, nurse, doctor, attorney, etc…), please let us know here

Please let us know what days of the week (Monday through Saturday) and what times (morning, afternoon, evening) might be most suitable for your appointments.

We cannot guarantee an appointment time until you’ve scheduled your first appointment but this will help us match you with one our counselors based on availability.

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Second Choice

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