1. Intake Form: Child/Adolescent
Date: ____________
Name of Child: _________________________________ Date of Birth ____/_____/______
Motherʼs Name (age): ____________________ Fatherʼs name (age) ______________________
Address: _______________________________________________________________________
Street City State Zip
Home Phone: ____________________ Parentʼs Cell: __________________________________
Work: ___________________ Childʼs Cell Phone _________________________________
Parentʼs marital Status: Married Divorced Separated (If separated/divorced, since when) _____
Person responsible for payment _______________________________________________
Referred by: _________________________________
Notify in case of emergency: _______________________Phone:_____________________
Religious Affiliation: _________________________________________________________
Home schooled? Y N Grade: ___________ School _______________________________
Other members of the household: ________________age_____ Relation: __________________
________________age______ Relation: __________________
________________age______ Relation: __________________
________________age______ Relation: __________________
What are the reasons you are seeking help at this time? __________________________________
SLP Counseling, Inc. 304 1/2 East Main Street
Wilmore, KY 30490
Phone: (859) 858-2619