Confidential Youth Intake Information Questionnaire


Youth Intake

Parents/Guardians

Currently living with you?

Siblings

Currently living with you?

Have you ever seen a school counselor or psychologist?
Have you ever been seen by a probation officer?

Have you been in counseling before?
Was counseling helpful?

Please check any of the following that are currently troubling you:

At any time in your life, have you thought about hurting or killing yourself?

Please be aware that cash or checks are the only form of payment accepted by the office. Full payment is expected at the time of your visit. If you have health insurance that covers psychological treatment please discuss this with the office staff to inquire about coverage and fill out the required forms. We generally operate very much on time so please be prompt for your appointment or your appointment may be cut short due to starting late.

Since your appointment time is reserved exclusively for you, or cancellation policy is as follows:
Appointments must be canceled 24 hours in advance. Appointments which are not given a 24 hour notice and/or missed appointments without cancellation will be subject to the full fee, as if the appointment was kept. Since insurance companies do not pay for missed appointments, this fee is the sole responsibility of the person responsible for payment, and cannot be billed to your insurance. Thank you for your cooperation.

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