Child Intake Form Name Date of Birth Age Male or Female Male Female Street Address City State Zip Primary Guardian Relationship to Child Street Address City State Zip Primary phone # Is it OK to leave a message? Yes No Secondary Phone # Is it OK to leave a message? Yes No Secondary Guardian Relationship to Child Street Address City State Zip Primary Phone # Is it OK to leave a message? Yes No Secondary Phone # Is it OK to leave a message? Yes No Are both the primary and secondary guardian allowed to have contact with the child client? * Yes No Third Choice Please indicate if there are specific rules regarding contact, custody or other powers or limits of powers related to either guardian. Please provide a copy of the custody agreement if relevant, as enrollment in therapy cannot occur without the consent of both legal guardians when applicable. How did you learn of Encompass Mental Health? Health Insurance Provider Health Insurance ID/Group Number Name of Policy Holder Policy Holder’s DOB Relationship to Client List the names, ages, and relationship of all family members with whom the child lives: School Currently Attending Grade Name of Teacher Did this teacher refer you? Yes No Previous Counseling Experience Briefly explain the reason for seeking counseling: Primary Care Physician Hospital/Clinic Name Date of Most Recent Exam/Physical Medical Problems/Diagnoses Medications Unusual Health Background or Experiences? Parent’s Home Rent Own Residential Care/Treatment Facility Hospital Residential Care Temporary Housing Nursing Home Other Friend’s Home Homeless Relative/Guardian’s Home Foster Home Submit
