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.
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:
Date of Birth:
School and Grade:
Counseling I am seeking:
Never submit passwords through Google Forms.
This form was created inside of Cumberland Community Church.