Adolescent/Child Intake (17 and below)
Please fill out this intake form before receiving counseling services. If your child is 18 years old, please have he/she fill out an adult intake form.
* Required
Who are you meeting with?
*
Alexandra Thompson, LCSW
Mayra Richards, LPC
Victoria Marie Hicks, LPC, AMFT
Robert Vore, APC
Katherine Kessler, LMSW
Adolescent/ Child’s Name:
*
Your answer
Age:
*
Your answer
Date of Birth:
*
MM
/
DD
/
YYYY
School and Grade:
*
Your answer
Counseling I am seeking:
*
individual
family
spiritual/pastoral
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