Client Forms New Client Intake Form Patient Intake Today's Date MM DD YYYY Patient Information Name * First Name Last Name Date of Birth * MM DD YYYY Male or Female Male Female Address * Address 1 Address 2 City State/Province Zip/Postal Code Country School * Grade * Pre-K Kindergarden 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade 7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Pediatrician * Pediatrician's Phone Number * (###) ### #### Parent/Guardian Information Parent/Guardian Name * First Name Last Name Same address as patient Different address from patient Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Email * Parent/Guardian Name First Name Last Name Same address as patient Different address from patient Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Do both parents of the child live together? * YES NO If NO, who has... PRIMARY PHYSICAL custody Mother Father PRIMARY LEGAL custody Mother Father Emergency Contact Name * First Name Last Name Phone * (###) ### #### Thank you! HIPPA Form Consent for Treatment Release of Information
