Therapy Intake Form Patient's Name * First Name Last Name Child's Date of Birth (or your own if seeking treatment services for yourself) * MM DD YYYY Preferred Phone Number Country (###) ### #### Is it okay to leave a voicemail? Yes No Preferred Email Address Is it okay to E-mail? Yes No Is this referral for yourself or your child? If for yourself, skip to question 10. Myself My Child If the referral is for your child, please list all guardians and in the case of separation/divorce, indicate who has medical decision making authority: In the case of separation/divorce, are parents struggling to co-parent effectively or is there conflict in the parenting relationship? Please briefly describe the main concerns you are seeking help for at this time. Is there any other information that you think would be relevant for us to know at this point? Does your child/teen have a neurodivergent or neurodevelopmental condition that affects their ability to communicate and/or their level of independence (e.g., autism, intellectual/developmental disability)? If yes, please briefly describe: If yes, how does your child/teen communicate their needs when they are calm and comfortable? Does not communicate using words, relies heavily on others and/or assistive communication tools Speaks a few words but often requires prompts or assistance to communicate Communicates some needs effectively with words but may require prompting and/or help for more complex communication Communicates needs verbally without assistance at a level similar to most others their age If yes, how well does your child/teen understand and follow spoken directions? Not at all Understands very few spoken instructions Can follow some simple instructions but often needs more communication help than most others their age Understands most spoken directions and can follow simple instructions without help, but struggles more than same-age peers with more complex tasks Consistently understands and follows simple and complex directions without help at a level similar to others their age Is there a specific psychologist(s) that you wish to work with? In matching you with a psychologist, do you have any preferences you would like us to consider? What type of service are you looking for? * In person Virtual Either/both How did you hear about our clinic? Are there any specific services you are looking for (e.g., groups, workshops, intensives, etc.)? Thank you! Our office manager will be in touch within the next week to take you through the next steps.
