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CLIENT DETAILS

CHILD'S INFORMATION

Child's Name

PARENT INFORMATION

Parent #1 Name
Parent #1 Mailing Address
Parent #2 Name
Parent #2 Mailing Address

SIBLING INFORMATION

Sibling #1 Name
Sibling #2 Name
Sibling #3 Name

FINAL STEPS

If you are divorced from the biological parent of the child(ren) you are seeking therapy for, do you have a divorce decree or legal document that states who can consent to counseling?
If you are the legal guardian of the child that counseling is being sought for, do you have legal documentation that states you can consent to therapy?

Legal Documentation Notice

*Please email prior to your session or bring a copy of your signed divorce decree/legal document regarding ability to consent to the counseling of a minor(s) to your Parent Intake session.