Child/ Teen Intake Form

Child / Teen Information

Child’s First Name
Child’s Last Name
Date of Birth
Age & Grade
School Currently Attending
Other Schools Attended

Parent / Guardian Information

Parent/Guardian 1

First Name
Last Name
Email
Phone

Parent/Guardian 2

First Name
Last Name
Email
Phone

Family & Household

Does the child live with both parents?
YesNo

Custody Agreement
Who else lives in the home?
Reason for Seeking Services

Is the child currently taking any medication?
YesNo

Medication & Prescribing Doctor

Has the child ever completed an evaluation?
YesNo

Evaluation Purpose & Results

Areas of Concern:
AnxietyDepressionBehavioralSocial SkillsSelf-esteemAngerOther

How did you hear about Shine Bright Counseling?

Shine Bright Counseling Required Forms

Please review the following forms before completing this intake:

Open Shine Bright Counseling Required Forms

Please confirm that you have read and agree to the following:

Consent to Treatment and Confidentiality formComplaint Process formTelemental Health Informed Consent formNotice of HIPAA Privacy Policies formConsumer Consent Disclosure form

Electronic Signature (Acknowledgment Required)
I understand and accept that my electronic signature will be as valid as a handwritten signature and considered original to the extent allowed by applicable law.