4 Star Guidance Intake Form (90 seconds)
Thanks for reaching out! Fill out this very short form and one of our team members will be in touch within 24-48 hours about next steps. We look forward to talking with you soon.  

Questions? Call us!  (502) 883-7828 or email: contact@4starguidance.com 
Sign in to Google to save your progress. Learn more
Your Name *
Child's Name *
Gender *
Name of the Child's School *
Phone *
Email *
Client's Address *
1. What is your child's birthday and what grade are they currently in?
 *
2.  Does your child experience anxiety or nervousness? *
3.  Have you noticed any signs of sadness or withdrawal? *
4. Has your child had challenges with attention and completing tasks? (ADHD symptoms) *
(OPTIONAL) 4a. If you answered yes, could you provide examples?
5. Has your child expressed any oppositional behaviors? (Rebelling, trouble with peers, parents, teachers, etc.) *
6. Does your child display any signs of anger, irritability, or have emotional outbursts? *
(OPTIONAL)6a. If you answered yes, how frequently do these occur? 
7. Have you noticed any signs of restlessness or hyperactivity? (e.g., fidgeting, restless leg) *
(OPTIONAL) 7a. If you answered yes, in what settings do you observe these behaviors most?
8. Have you reached out for support or interventions in the past? *
9. Does your family have a history of similar conditions? *
10. Are you in need of immediate support resources? *
11. Is your child covered by commercial insurance or a managed care plan? *
12. What is your insurance policy number? (Please include the effective AND expiration date)
13. Please provide a preferred start date. *
MM
/
DD
/
YYYY
13. When are you available for an initial consultation? *
14. If you have any additional concerns or questions, please specify below.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Christopher Key.

Does this form look suspicious? Report

Google Forms