Adolescent/Child Intake
please fill out this intake form before receiving counseling services
* Required
Child’s Name:
*
Your answer
Counseling I am seeking:
*
individual
family
spiritual/pastoral
Age:
*
Your answer
Date of Birth:
*
MM
/
DD
/
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:
*
Male
Female
Other:
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?
*
Yes
No
Email address:
*
Your answer
I am:
*
single
married
divorced
engaged
Parent #2 Name:
Your answer
Parent #2 Marital Status:
Your answer
Parent #2 Gender:
Male
Female
Address:
Your answer
Best number to reach parent #2 on:
Your answer
Secondary number:
Your answer
Can we leave a confidential voice mail?
Yes
No
Email address:
Your answer
Step Parent's Name:
Your answer
Marital Status:
Your answer
Step Parent's Gender:
Male
Female
Other:
Address:
Your answer
Best number to reach Step Parent on:
Your answer
Secondary number:
Your answer
Can we leave a confidential voice mail?
Yes
No
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?
Yes
No
If not aware, please explain:
Your answer
If adopted, does your child know of the adoption?
Yes
No
Other:
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:
*
employed/self-employed
unemployed
retired
student
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?
*
Yes
No
Are you interested in group counseling?
*
Yes
No
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?
*
Yes
No
Is she/he considering this currently?
*
Yes
No
Unknown
Is there anything else you’d like the clinician to know (or write n/a)?
*
Your answer
Approx. annual income?
$29,000 and below
$30,000-$40,000
$41,000-$50,000
$51,000-$60,000
$61,000-$70,000
$71,000-$80,000
$81,000-$90,000
$91,000-$100,000
$101,000 and above
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.
*
Yes
No
Signature (by typing full legal name):
*
Your answer
Relationship to child:
*
Your answer
Today's Date:
*
MM
/
DD
/
YYYY
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