Child Intake Form
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8Child Intake Form
West Houston Counseling Center, PLLC
707 South Fry Rd., Suite 465, Katy, Texas 77450
Phone: (281) 940-8515 Fax: (888) 972-1582
Child Information:
Name: ________________________________________ Today’s Date: _______________________ Sex: M
F
Age: _____ Birth date: ________________
Grade: _____________ School: _____________________________
Parent Information:
Name: ___________________________________________________ Relationship to child: ___________________
Custody/Court Papers: Y N
Right to seek counseling services? Y N
Sex: M F
Occupation: _______________________________________________ Birth date: ________________________
Address: ______________________________________________________________________________________
Home Phone: ______________________________ Cell Phone: _______________________________________
Email Address: ____________________________________ Permission to confirm appointments via email? Y N
Are you remarried? Y N
Name of Spouse: _______________________________________________
Other Parent:
Name: _________________________________________________ Relationship to child: _____________________
Sex: M F
Occupation: _________________________________________ Birth date: _____________________
Address: _________________________________________________________________________________________
Home Phone: ____________________________
Cell Phone: ___________________________________________
Email Address: __________________________________ Permission to confirm appointments via email? Y N
Are you remarried? Y N
Name of Spouse: _______________________________________________
In the event of an emergency, whom should we contact?
Name: __________________________________________ Relationship: _____________________________________
Cell Phone: _____________________________________ Email: _________________________________________
Please provide a copy of both sides of your insurance card and driver’s license for verification of benefits and identity.
Responsible Party
Name: _____________________________________________________ Birth Date: _________________________
Address: ______________________________________________________________________________________
Driver’s License # _____________________
SS#_________________________ Phone:_________________________
INSURANCE INFORMATION
Who is the insured? _______________________________ SS#: _____________________ Birth Date: ______________
Relationship to Client: ___________________________________________ Cell Phone: ________________________
Employer of the insured: __________________________________________ Work Phone: ________________________
Insurance Company Name:_________________________ Insurance Phone # for Mental Health: ___________________
Member ID#: _____________________________________ Group ID#:______________________________________
I authorize the release of any medical or other information necessary to process an insurance claim. I understand that West Houston
Counseling Center, PLLC will diligently attempt to get accurate information regarding my mental health insurance benefits. I will not
hold West Houston Counseling Center liable for insurance nonpayment due to misquoted benefits. I will not hold West Houston
Counseling Center responsible to know and understand my benefits plan. West Houston Counseling Center will file my insurance
claims for me as a courtesy. I am ultimately responsible for all charges my insurance company does not pay, except for contracted
network provider discounts that may apply. I also request benefits be paid to West Houston Counseling Center.
Signature of Client and/or Responsible Party: __________________________________Date: ___________________
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