Child and Adolescent Intake

For Ages 4 & Up

If you have any trouble submitting this form, please download and print the pdf and fax it to us at (703) 530-9805.Download

CHILD INFORMATION

Child's Name*

Date of Birth

Address

City

State

Zip

SSN

Last grade completed in school

Grade Average

Name of School

MOTHER'S INFORMATION

Name*

Date of Birth

SSN

Address

City

State

Zip

Highest Grade Completed

Occupation

Place of Employment

Home Phone*

Work Phone

Cell Phone*

Email Address*

Religious Affiliation

FATHER'S INFORMATION

Name

Date of Birth

SSN

Address

City

State

Zip

Highest Grade Completed

Occupation

Place of Employment

Home Phone

Work Phone

Cell Phone

Email Address

Religious Affiliation

STEP-PARENT / GUARDIAN INFORMATION

Name

Date of Birth

SSN

Address

City

State

Zip

Highest Grade Completed

Occupation

Place of Employment

Home Phone

Work Phone

Cell Phone

Email Address

Religious Affiliation

REFERRAL INFORMATION

How did you find us (referred by doctor, friend, family, church, other)

INSURANCE INFORMATION

Insurance Company

Policy/Group #

Address

City

State

Zip

Phone number

Insurance Type HMO
PPO

Has deductible been met? Yes No

Does your insurance company require prior authorization? Yes No

If so, please provide the authorization number #

Parent / Guarding Digital Signature

Verification

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