Intake Form | The School Counseling Group

Student's Full Name *

First

Last

Preferred Name

Student's Preferred Pronouns *

Date of Birth

Student's Email

Student's Cell Phone

Current School

Current Grade

Schools Previously Attended

Please include name of school(s) and grades attended.

Is the student an American Citizen?

Is your child:

Age at Adoption

Does the student have an Indvidual Education Plan (IEP) or a 504 Plan at School?

Has the student ever completed educational or psychological testing?

Student's present diagnosis, if any:

Student's prescription medication and amounts, if any:

Does the student have any allergies?

If yes, please list:

Parent/Guardian 1

Parent/Guardian Name *

First

Last

Preferred Name

Address

Address Line 1

City

State / Province / Region

Postal Code

Country

Phone *

Email *

Parent/Guardian 2

Name

First

Last

Preferred Name

Address

Same as Parent 1 Above

Parent 2 Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Parents' Marital Status (check all that apply):

Are there any custody issues?

If yes, please explain:

Siblings

Please list names, ages and current school.

Siblings