Child Intake Form

Child's Name
Child's Gender
Does Your Child Have Any Siblings?

Please provide first and last name

Parent Gender

Please provide first and last name

Parent Gender
Can messages be left at this number?
Has your child had previous (or current) counselling?
Was It Helpful?
Has your child experienced any of the following?
Is there a police file open?
Are there charges active or pending?
Do you have a case worker through Child and Family Services?
Are other agencies involved?

(Documentation required)

Source of Family Income:
Housing Situation of Family:
Marital Status of Parents:

(select all that apply)

Ethnic Culture:

This question refers to the ethnic or cultural origins of a person's ancestry, who we identify as, or what environment we are from.

Religious Culture

This question refers to how your child has been raised, based on the moral/social principles we use to govern our lives, and how we view the world.

Are there any known diagnoses?

(History of concerns, nature and length of relationships in the home, impacts you or others have noticed.)