Roland Gabbert, LCSW, Psychotherapist
Child Intake Information
Print and Sign
Child Intake Information
Name (of child):_________________________
Phone #:____________Cell#___________
Address: ____________________________ City:___________________Zip:__________
SS#:_____________________________________ Age:_____
Birth date:_____________
School:______________________________
Education Level:__________________
Father:___________________________ Address:________________________________
Father's Employer:___________________________________ Phone:_______________
Mother:__________________________ Address:________________________________
Mother's Employer:___________________________________ Phone:_______________
If applicable:
Step-father:_________________________Address:______________________________
Step-mother:________________________Address:______________________________
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~In case of emergency, contact:___________________________Phone:_______________
Family Physician:_____________________________________Phone:______________
Names of Siblings:________________________________________________________
Who referred you to this office?______________________________________________
May I contact you at work regarding your appointment?:__________________________
In the event I am unable to contact you, with whom may I leave a message regarding your appointment?:______________________________
Primary Insurance Co.:_____________________________________________________
Subscriber's Name:_____________________SS#____________________Birth date:____________
ID #:__________________ Group #:____________
************************************************************
Secondary Insurance Co:______________________________________________
Subscriber's Name:_____________________SS#____________________Birth date:____________
ID #:__________________Group #:____________
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SIGNED:______________________________________Date:_________________
(Patient/Responsible Party)
Witness:___________________________________________________________
