Name of Child/Adolescent *

First Name

Last Name

Child's Date of Birth

MM

DD

YYYY

Date of Diagnoses

MM

DD

YYYY

Child's Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Indicate Parents/Guardians Living in the Home

Marital Status

Married

Divorced

Separated

Widowed

Single Cohabitants

Is it Joint or full Custody?

Joint

Full

Is it Joint or full Custody?

Joint

Full

Parent/Guardian Name

First Name

Last Name

Parent/Guardian Date of Birth

MM

DD

YYYY

Employer Phone

(###)

###

####

Mobile Phone *

(###)

###

####

Parent/Guardian

First Name

Last Name

Parent/Guardian Date of Birth

MM

DD

YYYY

Employer Phone

(###)

###

####

Mobile Phone *

(###)

###

####

Insured Address (if different than address already listed)

(TriCare cases only) Must have military ID on file

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

DOD

MM

DD

YYYY

Does your child have a Primary Care Physician?

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Does your child currently receive treatment from a Behavioral Health provider?

Yes

No

When did services end or When will services end?

MM

DD

YYYY

Do you have a Diagnostic Assessment?

We will need copy.

Yes

No

If your child has been in Special Education, did they have a:

We will need copies of all reports and treatment plans

504 Plan

I.E.P

Psychological Evaluation

Speech Evaluation

Behavior Intervention Plan

Occupational Therapy Evaluation

Physical Therapy Evaluation

Adaptive Technology Evaluation

Other

Therapist Preference

Male

Female

Child's Availability Preference

Mondays

Tuesdays

Wednesdays

Thursdays

Fridays

Saturdays

Sundays

Child's Time Availability Preference

Morning

Mid Day

Afternoon

Name of local friend or relative

(not living at same address)

First Name

Last Name

Phone

(###)

###

####

Date

MM

DD

YYYY