SCG Intake Form: Schools 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 * Student's Cell Phone * Current School * Current Grade * Schools Previously Attended Please include name of school(s) and grades attended. 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 If applicable, please share more about your child's learning differences and/or any current or past diagnoses. Parent/Guardian 1 Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * Email * Parent/Guardian 2 Name First Name Last 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 How did you hear about The School Counseling Group? Friends/Family School/Program Repeat Client/Family Professional Internet Other 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. If you need to complete an additional intake form for another child, please follow the link below.Additional Intake Form
