Counseling Client Intake Form

Please correct the errors described below.

The purpose of the questionnaire is to help us obtain information about your child and family to aid us in providing the best health care possible. Please answer all questions as they apply to your child. If a question does not apply or you prefer not to answer, leave it blank. If you do not understand a question, please please write don't understand so we can explain it further. This questionnaire will become part of your child’s health record, and as such will be strictly confidential.

Parental Consent to Treat a Minor

to be treated by Amelia P. Lincoln, MEd, MCMHC, in counseling. I also understand that in order to be successful with any individual, their confidentiality needs to be respected, even in the case of a minor child, with the exceptions of if the child is a danger to himself/herself or to others. I understand that this permission to treat with respect for my child’s confidentiality is given with my full consent. This consent will be valid throughout the duration of therapy.

Disclaimer: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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