Child Intake

Child Form 01/14 Demographics

  • alternatetext

    Demographic Verification

Child Form 02/14 Intake Procedures

  • alternatetext

    Intake Procedures

Child Form 03/14 Freedom of Choice

  • alternatetext

    Freedom of Choice Statement

Child Form 04/14 Financial Responsibility

  • alternatetext

    Financial Responsibility & Release

Child Form 05/14 Parental Consent

  • alternatetext

    Guardian/Parent Consent

  • Consent of both parents/guardians may be required for treatment

    Documentation may be required.

Child Form 06/14 Informed Consent

  • alternatetext

    Informed Consent

Child Form 07/14 PHI Disclosure

  • alternatetext

    Protected Health Information (PHI) Disclosure

Child Form 08/14 No Show Cancellation Policy

  • alternatetext

    Cancellation/No-Show Policy

Child Form 10/14 Overweight Risk Assessment

  • alternatetext

    Child Overweight Risk Assessment

  • Instructions for this form.

    Through these questions, please read the full question carefully. After reading the question, if you feel that the answer is "Yes" please indicate your answer with a 1 in the field. If you feel that the answer is "No" please indicate your answer with a 0 in the field.
  • Interpretation:

    0-2 ‘Yes’ answers:
    Your child’s overweight risk is low. A child’s overweight risk can change as their eating and activity habits change. Learn the overweight risk factors and encourage changes of your child develops any risk factors.

    3-4 ‘Yes’ answers:
    Your child’s overweight risk is moderate. You can help your child lower their overweight risk by slowly introducing them to a more active lifestyle and healthier eating habits.

    5+ ‘Yes’ answers:
    Your child’s overweight risk is high. Help your child lower their overweight risk by slowly introducing them to a more active lifestyle and healthier eating habits.

    These assessments should be used for education about medical conditions only and are not for providing medical diagnosis. Only a health care professional can diagnose and recommend treatment. You are advised to promptly check with a physician if a medical condition exists or is suspected.

Child form 12/14 SCARED

  • alternatetext

    Screen for Child Anxiety Related Disorders

  • Directions
    Below is a list of statements that describe how people feel. Read each statement carefully and decide if it is "Not True or Hardly Ever True" or "Somewhat True or Sometimes True" or "Very True or Often True" for your child. Then for each statement, fill in one circle that corresponds to the response that seems to describe your child for the last 3 months. Please respond to all statements as well as you can, even if some do not seem to concern your child.

Child Form 13/14 ODD Behavioral Rating Scale

  • alternatetext

    ODD Behavioral Rating Scale

Child Form 14/14 Encounter Form

  • alternatetext

    Encounter Form