Intake Form Student's Full Name * First Name Last Name Preferred Name Student's Preferred Pronouns * He/him/his She/her/hers They/them/theirs Other Date of Birth MM DD YYYY Student's Email Current School Current Grade Schools Previously Attended Please include name of school(s) and grades attended. Is the student an American Citizen? Yes No Is your child: Biological Adopted Does the student have an Individual Education Plan (IEP) or a 504 plan at School? Yes No Has the student ever completed educational or psychological testing? Yes No Student's present diagnosis, if any: Student's prescription medication and dosage, if any: Does the student have any allergies? Yes No If yes, please list: Parent/Guardian 1 Name * First Name Last Name Preferred Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Email * Parent/Guardian 2 Name First Name Last Name Preferred Name Address Same as Parent 1 Above Parent 2 Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Email Parents' Marital Status (check all that apply) Single Married Divorced Partnership Mother Deceased Mother Remarried Are there any custody issues? No Yes Siblings Please list names, ages, and current school. How did you hear about The School Counseling Group? Friends/Family School/Program Repeat Client/Family Professional Internet Other Please share the name of the referrer. Is there any other information that you want to share that you didn't discuss on your initial call? Thanks for completing the intake form. Please be sure to return to your email to complete the remaining paperwork.
