Child And Adolescent Intake Form Date Patient Infromation Legal Name (required) Preferred Name Social Security Number [ssn] Date of Birth Gender Age Street Address City State Zip Code 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 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? YesNo May we leave voice mail regarding appointments? YesNo May we leave messages regarding your appointments with others who may answer your number? YesNo By typing your name you have created an electronic signature as legally binding as your handwritten signature. Child/Adolescent Signature Signature of Legal Guardian If parents are divorced and legal custody is shared, we need the signature of both legal guardians. Signature of Legal Guardian 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.