“Helping Kids to Achieve Their Personal Best”

Intake Information Form

Your Child                                                

Child’s Name:  _____________________________________________________________

Date of Birth:    __________________________ Sex: (please circle)     Male      Female

Current School/Grade: ________________________________________________________

Referred By:  ________________________________________________________________

Your Family

Mother’s Name (First Name) _____________________(Last Name) ____________________

Father’s Name (First Name)  _____________________(Last Name) ____________________

Home Address:_______________________________________________________________

(City/State) __________________ (Zip code) _______ E-mail ________________________

Telephone Numbers: (Home) _________________   (Work/Mobile):  ___________________

BC/BS Health Insurance Policy Number:_________________________________________

Name of Insured Party:________________________________________________________

Reason for Referral:  Current Concerns about Your Child?

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Has Your Child Ever Been Tested?  Where?  When?  What was learned?

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