Adolescent/Child Intake
please fill out this intake form before receiving counseling services
Child’s Name:
Your answer
Counseling I am seeking:
Age:
Your answer
Date of Birth:
MM
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DD
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YYYY
School:
Your answer
Grade:
Your answer
Teacher:
Your answer
Sibling name, age, DOB (all siblings):
Your answer
Parent/Guardian's Name (completing form):
Your answer
Marital Status:
Your answer
Parent Gender:
Address:
Your answer
Best number to reach you on:
Your answer
Secondary number (or write n/a):
Your answer
Can we leave a confidential voicemail?
Email address:
Your answer
I am:
Parent #2 Name:
Your answer
Marital Status:
Your answer
Parent #2 Gender:
Address:
Your answer
Best number to reach parent #2 on:
Your answer
Secondary number:
Your answer
Can we leave a confidential voice mail?
Email address:
Your answer
Step Parent's Name:
Your answer
Marital Status:
Your answer
Step Parent's Gender:
Address:
Your answer
Best number to reach Step Parent on:
Your answer
Secondary number:
Your answer
Can we leave a confidential voice mail?
Email address:
Your answer
For parents who are divorced, please state custody arrangements:
Your answer
Is ex-spouse (biological parent) aware that you are bringing your/their child to CCC counseling?
If not aware, please explain:
Your answer
If adopted, does your child know of the adoption?
What age was your child at the time of the adoption?
Your answer
How did you hear about the counseling program at Cumberland Community Church?
Your answer
Employment Status:
What is your occupation?
Your answer
Emergency contact name:
Your answer
Relationship:
Your answer
Phone number:
Your answer
Please list any medications your child is currently taking (mental health related. Or type n/a):
Your answer
Please list any major medical problems your child currently has (including if any require medication. Or type n/a):
Your answer
Have you or your family received counseling services from Cumberland Community Church before?
Are you interested in group counseling?
If you are interested in group counseling, what kind? (or type not interested)
Your answer
Please describe your current reasons for seeking counseling at this time. If there is a particular event which triggered your decision, please list this event:
Your answer
What do you hope to achieve/address through counseling?
Your answer
What are your religious or spiritual beliefs?
Your answer
Are you aware of your child ever strongly considering to or attempting to taking his/her own life?
Is she/he considering this currently?
Is there anything else you’d like the clinician to know (or write n/a)?
Your answer
I am the parent/legal guardian of the child listed above with full legal Authority to consent to treatment. I give permission for a Cumberland Community Church/The Collective counselor to provide treatment for this child which may include assessment, advocacy, referral, and mental health/pastoral counseling.
Signature (by typing full legal name):
Your answer
Relationship to child:
Your answer
Today's Date:
MM
/
DD
/
YYYY
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