Child and Adolescent Intake Form

Insurance Information

Current Symptoms / Behavioral Observation

Education

Developmental History

Please check the appropriate box for symptoms your child has experienced in the past 2 weeks.

A DETERMINATION AS TO THE MOST APPROPIATE SERVICES FOR EACH CONSUMER WILL BE MADE BASED ON THIS INFORMATION: THEREFORE, IT IS IMPORTANT TO KNOW AS MUCH AS POSSIBLE ABOUT EACH APPLICANT. WE ASK THAT YOU PROVIDE THE ABOVE INFORMATION IN ITS ENTIRETY BEFORE WE START WORKING WITH THE CHILD, SO THAТ WE CAN MAKE A ACCURATE ASSESSMENT OF SERVICES NEEDED.

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