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Align Your Life
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Child Intake Form
First name
Last name
Birthday
Month
Month
Day
Year
Address
Name of person completing the form & relationship to the child
Date
Month
Month
Day
Year
Race & Ethnicity
Mother & Father's First & Last Name
Are parents married, separated, divorced or widowed?
Siblings Names & Ages
Who suggested your child should seek assessment or counseling?
Describe any over all issues that led you to seek help for your child
Does your child have any issues with family members? If so, please describe
Do you have reason to believe your child has been abused? Emotionally, physically or sexually?
Describe your child's school experience
Describe your child's relationships with parents and siblings
Does your child appear to have high levels of stress?
Describe any family medical or emotional history
Does your child have any medical issues?
Submit
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