Intake Form

Intake Form

IDENTIFYING INFORMATION





BACKGROUND INFORMATION


DEVELOPMENT HISTORY:


At your child’s birth, how old was:

During pregnancy, did mother take any:

Age of mastery of the following milestones:

MEDICAL HEALTH TREATMENT HISTORY



-If yes, please answer the following:



BEHAVIORAL HEALTH TREATMENT HISTORY


FAMILY TREATMENT MEDICAL HISTORY


ENVIRONMENTAL VARIABLES


FOSTER CARE (IF APPLICABLE)


COORDINATION OF CARE

CONSENT TO RELEASE INFORMATION WITH THE FOLLOWING PROVIDERS


ACKNOWLEDGEMENT


Working Hours
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