Child Intake Form
Please complete this form at least 24 hours prior to your intake appointment. This form is processed through a secure channel (via a HIPAA compliant Google App account). Also, I only request your initials and your child's initials (as opposed to full names) on this form as an extra precaution.
Email address *
Child’s First and Last Initials: *
Birth Date: *
month/day/year
Age: *
Your child's preferred pronoun
Clear selection
Child’s ethnicity: *
Child’s current school: *
Current grade: (or, if summer, what grade will he or she be entering in the fall) *
Current city of residence: *
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