Intake Form

Intake Form

IDENTIFYING INFORMATION





BACKGROUND INFORMATION


DEVELOPMENT HISTORY:


At your child’s birth, how old was:

During pregnancy, did mother take any:

Age of mastery of the following milestones:

MEDICAL HEALTH TREATMENT HISTORY



-If yes, please answer the following:



BEHAVIORAL HEALTH TREATMENT HISTORY


FAMILY TREATMENT MEDICAL HISTORY


ENVIRONMENTAL VARIABLES


FOSTER CARE (IF APPLICABLE)


COORDINATION OF CARE

CONSENT TO RELEASE INFORMATION WITH THE FOLLOWING PROVIDERS


ACKNOWLEDGEMENT


Our Address
1515 N. Gilbert Rd.
Gilbert, AZ 85234
Phone Number
(480) 999-7779
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