Parent Intake Form - Jackson Hole Family Solutions

Basic Information

Name of Mother

First Last

Name of Father

First Last

Name of Child seeking treatment*

First Last

Age of Child seeking treatment

Please List Name/Age of all Siblings

Please list school & grade of child seeking treatment

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Mother

Phone Father

Email Mother

Email Father

Child History & Info

Has child used substances*

Yes
No
this is a current concern
past occurrence, not immediate concern
child has received previous treatment for this issue
Uncertain

If yes, please list substances and last date of use

Is there a history of suicide ideation/attempt*

Yes
No
this is a current concern
this is a past occurrence, but not immediate concern
child has received previous treatment for this issue
uncertain

Is there a history of eating disorder*

Yes
No
this is a current concern
this is a past occurrence, but not immediate concern
child has received previous treatment for this issue
uncertain

Is there history of cutting or other self inflicting harm behaviors*

Yes
No
this is a current concern
this is a past occurrence, but not immediate concern
child has received previous treatment for this issue
Uncertain

Is child sexually active?

Yes
No
Uncertain

Is there history of sexual abuse/trauma*

Yes
No
this is a current concern
this is past occurrence, but not immediate concern
child has received previous treatment for this issue
Uncertain

Have you noticed shifts/changes in the last 6 months in any of the following areas*

academic performance
peer relationships
family relationships
recreational activities
substance use/abuse
Uncertain

If yes to any of above, please briefly explain

Payment Consent & Information

I have read, understand & authorize the following payment policies (checking the boxes below indicates approval response "yes"):*

Credit card will be held on file and charged accordingly on dates of service
Late cancellations (less than 24 hours) will yield a full fee payment for hour
I will be charged full payment for “no show” sessions
I authorize payments for services, late cancellations and no show fees accordingly

Credit Card Information – this is a HIPPA compliant secure site*

Please include: 1. credit card number 2. expiration date 3. CVV 4. Zip Code

Parent Insight

Mother: Please briefly list any additional concerns regarding child's behavior or history

Mother: Please identify goals for therapy in regards to this child

Father: Please briefly list any additional concerns regarding child's behavior, history

Father: Please identify goals for therapy in regards to this child

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Name

This field is for validation purposes and should be left unchanged.

Laura Santomauro, LMFT

Laura Santomauro, LMFT

Parent Intake

Basic Information

Child History & Info

Payment Consent & Information

Parent Insight