INTAKE FORM

*If this is an emergency please call 911. Do to the amount of cases, expect at least 2-3 business days for us to get back with you. Please fill out the following form in order for us to process your information.

Southern Christian serves children and youth 23 years and younger. Parents qualify for this service only if they have children ages 23 and younger.

PLEASE FILL OUT EVERY SPACE/REQUEST FOR INFORMATION TO BE PROCESSED.

Tell us why you're seeking an appt:

Name (Counseling Recipient)

Date * required

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Birthday

Age of person needing therapy

SS#

Guardian (legal guardian, if different)

Guardian Type: * Required

Parent

Foster Parent

Social Worker

Legal Guardian

Custodian Guardian

Guardian Cell Phone

Work

Home

Guardian Email:

Reasons for Seeking Therapy * Required

Grief

Crime Victim

Traumatic Event

Post Adoption

Depressive Symptoms

Anxiety Symptoms

Foster Care/Pre-Adoption

Behavioral

Anger Issues

Parent Child Interaction Therapy, 2 to 7 years old, behavioral therapy

Referral Source

Referral Name

Do you have insurance? If yes, please complete the below information. * Required

Yes

Insurance/Fee Information: (if applicable)

Insurance Company:

Policy/Group #:

Effective Date:

DOB

SS#

Insured Name:

Form Completed By:

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