Client Intake Form (Child, under 18)

Battlefield Counseling Centers

Please correct the errors described below.

Personal Information

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Parent or Guardian Information

Medical History

General Health Information

Family Mental Health History

In the section below, identify if there is a family history of any of the following. If yes, please indicate the family member's relationship to you (e.g. father, grandmother, uncle, etc.)

Additional Information

Emergency Contact Information

Your information will be encrypted.