Behavior Therapy Intake Form
Thank you for your interest in our clinical services. To help us better serve you, please provide us with the
information requested below. Please be assured that this information will be held confidential, and is necessary for the staff to determine appropriate evaluation and services.
Email address *
Child's Full Legal Name *
First and last name
Child's Gender *
First and last name
Child's Date of Birth *
MM
/
DD
/
YYYY
Child's Age *
Phone number *
Child's Current Address *
Primary Family Email *
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