Wellness Counseling Center

Helping People Connect

Child and Family Intake Form

Please complete the form below. We’ve notated in red font the responses that are required to continue to fill out this form. Remember to click the button at the end to submit your responses.

Type of Therapy(Required)

Child's Personal Information

Name
Address

Parent's Personal Information

Voicemail OK?(Required)
Text OK?(Required)

Voicemail OK?(Required)
Text OK?(Required)
*In the event of a separation/divorce/custody arrangement, please bring current Custody Order with you to your first parental appointment. We cannot see your child without this documentation.

Person to Reach in the Event of an Emergency:

Name:

Medical History of the Child

Has your child been in therapy previously?

Culture and Parent Relationship Status

Check all that apply:

Family & Family History

Family Stressors:

Child's Temperment

Sensitivity to change in touch, sound level, lighting:(Required)
Adaptability to schedule changes:(Required)
Ability to be calmed/soothed when distressed:(Required)
Regularity in sleep, eating:(Required)
Separating from parents:(Required)
Affection:(Required)

Developmental Milestones | School History | Social Development

Does your child have a 504 plan or IEP? (If yes, please bring a copy to your initial (parent) session.
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