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Child And Adolescent Intake Form

Patient Information









Preferred Phone Number
Preferred Email Address (required)
Father's Name
Preferred Phone Number for Father
Mother's Name
Preferred Phone for Mother
If there are step-parents please also list them:
Step-Father's Name
Preferred Phone Number for Step-Father
Step-Mother's Name
Preferred Phone for Step-Mother

Insurance Information

Information on Primary Insurance Company

Insurance Company
Policy Holders Name Social Security Number
Policy Holder's Address
Policy Holder's Date of Birth (if you are having troubles with the date not submitting use the following format yyyy/mm/dd)
Insurance ID
Policy Holder's Employer
Relationship of Patient to Policy Holder
Address of Insurance Company
We do not bill secondary insurance but will be happy to provide you with necessary information so that you can complete your billing to them.
Email address where statement should be sent
Physical address where statement could be sent

Please explain why you or your child/adolescent is seeking professional help at this time:

Please explain any recent event/s that may contribute to present symptoms:

May we contact you by phone or email regarding appointments?
May we leave voice mail regarding appointments?
May we leave messages regarding your appointments with others who may answer your number?

By typing your name you have created an electronic signature as legally binding as your handwritten signature.
Child/Adolescent Signature
First Name:
Last Name:
Signature of Legal Guardian:
First Name:
Last Name:
If parents are divorced and legal custody is shared, we need the signature of both legal guardians.
Signature of Legal Guardian
First Name:
Last Name:
Reminder emails and phone calls are a courtesy. At times, we may be unable to provide this service.
Remember that you are ultimately responsible for you scheduled appointments.

Phone: 801.438.6059 | Fax: 801.501.0249

Draper Office

248 East 13800 South, #4
Draper, UT 84020
801.438.6059

Bluffdale Office

14241 South Redwood Road Suite 100
Bluffdale, UT 84065
801.610.1573