Intake Form (Child and Adolescent)

Emergency Assistance

If this is an emergency, call:

Client Information

First name

Last name

Phone number

Date of birth

Email address for parent

Child's Address

Insurance

Please Note: In order to best understand your specific plan and coverage, we recommend calling your insurance company and speaking directly with a customer service representative to determine coverage for outpatient therapy (code 90837) in an outpatient OFFICE setting (code 11). Ask about your copay and deductible. Unfortunately, due to liability reasons, we no longer determine coverage on the client's behalf. We are happy to provide you with a form to help guide this process. When calling, ask if Karen Canada is in network even if you are being scheduled with another counselor. Some of the counselors bill under my number. As long as I am in network, they will be able to bill. Also, when calling, ask if they contract their mental and behavioral health services with another insurance company. Most do not, but some do. If they contract with a company that Oasis is not in network with, your services will NOT be covered by insurance even if Oasis is in-network with your medical plan. For example, we are in-network with Aetna, but we are NOT in-network with Magellan. If you have Aetna and your plan contracts their mental/behavioral health with Magellan, your services would not be covered under your insurance and would be considered private pay. If you have any questions about this, please do not hesitate to ask.

Does your child have a secondary insurance? If so, which is primary and which is secondary?

Policy Holder Name, Address, and Phone Number

Put N/A if no secondary insurance

Medical History

Has your child been treated by a doctor in the last 12 months?

Yes No

If yes, please describe the reason for your child's visit

Please briefly comment on anything you checked above.

Please let us know how we can help. What would you like your child to get out of counseling? What area of your child's life are you hoping will improve as a result of counseling?

Name of Parent or Legal Guardian #1

Address of Parent or Legal Guardian #1

Phone Number of Parent or Legal Guardian #1

Email Address of Parent or Legal Guardian #1

The parent or legal guardian listed above is in agreement with the minor receiving mental or behavioral health counseling from Oasis Counseling Center, Inc.

Yes, he or she is in agreement No, he or she is not in agreement If the parent or legal guardian is not in agreement, please comment on this in the space provided. Oasis's general policy is that both custodial parents/legal guardians consent to treatment. If parents are divorced and one parent can demonstrate legal primary or sole custody, please send the documentation to oasis@counselingmail.com

Name of Parent or Legal Guardian #2

Address of Parent or Legal Guardian #2

Phone Number of Parent or Legal Guardian #2

Email Address of Parent or Legal Guardian #2

The parent or legal guardian #2 is in agreement with the minor receiving mental health or behavioral health counseling.

Yes, this parent/legal guardian is in agreement with counseling for the minor listed. No, this parent/legal guardian is not in agreement with counseling services. If you checked no, please use the space provided to comment on why the parent/legal guardian is not in agreement. Please note: It is Oasis's policy, in general, to only provide services with the consent of both custodial parents/legal guardians.

Notice on Recommendations and Form Completion

Our primary service is the provision of clinical counseling. In some cases, a recommendation or form completion may naturally emerge from this process as part of the therapeutic work.

To preserve the integrity of the counseling profession, please understand that we do not provide recommendations for school, work, housing, disability or other purposes, nor do we complete forms, except for established clients with whom we have developed a working clinical relationship.

We recognize that requests for letters, recommendations, or form completion often feel urgent. However, this policy ensures that any statement we provide is grounded in professional knowledge of a client’s needs, abilities, and history. This protects both the client and the counselor by ensuring that all documentation reflects accurate, clinically-informed observations.

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