Child Intake Form

This form must be completed for children ages 17 and under.

Comprehensive Mental Health Services was founded in 1988. Since the beginning our plan has been to combine the personal attention of a private practice with the strength of a larger organization. Accordingly, we employ a broad range of clinicians, we offer a wide range of services and - within the practice - we contribute to one another's work.

Appointment Date

First Name

Middle Name

Last Name

Street Address

City

State

Zip Code

Home Phone

Parent 1 Cell

Parent 2 Cell

Date of Birth

Parent 1 Name

Parent 2 Name

E-Mail (Parent 1)

E-Mail (Parent 2)

Problems Being Encountered

Referred to this office by

Medical Information

Known Allergies

Medications

Pharmacy Name

Phone Number

Pediatrician and/or other practitioners seen regarding this problem

Known Medical Condition(s)

Your insurance is a method for you to receive reimbursement for fees you have paid to the physician for services rendered. Having insurance is not a substitute for payment. Many companies have fixed allowances or percentages based upon your contract with them, not with our office. We will do all that we can to assist you in receiving reimbursement, but you are responsible for your bill.

I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES. I HAVE READ THIS INFORMATION AND UNDERSTAND IT.

Signature

Date

Form Completed by

Relationship to Child

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