Child/Teen Intake Questionnaire

Please correct the errors described below.

Personal Information

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


General and Mental 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

Insurance Information

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