Psych and Life Skills/Social Skills Center

Intake Request Form

How did you hear about us?(Required)

Your Name(Required)

First Last

Phone(Required)

Your Email Address(Required)

Date of Birth of Client

Which office location:(Required)

Is this intake request for yourself or your child?(Required)

Name of Child(Required)

Age of Child(Required)

Grade of Child(Required)

Are you looking for a specific therapist?(Required)

Yes

Please Write Their Name(Required)

Do you prefer in-person or telehealth appointments?(Required)

In-person

Telehealth (Virtual)

Either one

Briefly describe why you are seeking treatment.(Required)

What insurance do you have?(Required)

Insurance Member ID: