Child Intake Form printable pdf download

Child Intake Form

Kristy Kirby, MFT #48653

Child Intake Form

Please fill out this biographical background form as completely as possible for your child. It will help me in

our work together. Information is confidential as outlined in the Office Policy form and the HIPAA Notice of

Privacy Practices. Please print or write clearly and bring it with you to the first session.

Identifying Information

Date __________________

Client’s Name: _______________________________________ DOB: _________ Age: __________

Person completing the form: _______________________________ Relationship: _______________

Address: _________________________________________________________________________

Home Phone Number: ________________________________ Cell: __________________________

Current School __________________________________Grade _____________________________

Child’s Physician __________________________________Date of last Exam: _________________

Medications child is currently taking: __________________________________________________

Reason you are seeking services for this child? (Please be specific) _______________________

_________________________________________________________________________________

How long has this been occurring? _____________________________________________________

Please list dates and counseling services previously received by the child:

Name

Dates

Reason for services

Please describe the child’s strengths, skills and supports: ___________________________________

_________________________________________________________________________________

Child Intake Form