Intake Form

Child, Adolescent, and Family
Psychological Services

Where families come together

To apply for services, please fill out this form. Or call us to schedule an intake by phone (206) 725-1820.
Intake Form

Name of Child:

Date of Birth: Age:

Parent/Caregivers Name:

Relation to Child:

Address:

Phone Numbers:
Home: Work:

Mobile: Email:

How did you find us? (Check all that apply)

Referral Source Friend
Insurance Company
Staff member at my child's school (Name):
Another mental health professional
Pediatrician
Other (please specify):

Area(s) of concern:

Services requested:
Individual/Family Therapy Assessment/Evaluation
Consultation

Insurance Information:

Company:
Regence Premera Magellan Behavioral Health Uniform Medical Plan Pacificare Aetna
Other Company:

Insurance company Phone Number:

Type of Plan:

Group #: Electronic Payer ID#

Claims Address:
(if known)

Subscriber Name:

Subscriber ID#:

Subscriber Date of Birth:

Subscriber's Employer:

If we do not have a time slot that fits your schedule, are you willing to be put on the waiting list? Yes No

Preferred Clinician First Choice:

Second Choice:

Third Choice:

Feel free to call our office if you have questions before filling out this form. Your information will be held within the strictest confidence and in compliance with the Health Information Portability and Accountability Act (HIPAA)

Completing this form does not obligate you to receive services from For A Child, LLC, nor does it obligate For A Child, LLC to serve you as a client. If you are in crisis and no clinician is available to assist you at the time of request, you may receive a referral for treatment.