Children’s Form

**ATTENTION! This is a form in addition to the online “New Client Health Info” form. This is only mandatory if you filled out the “New Client Health Info” form online. This form is also intended for children ages 17 and under. If the client is 18 and older, use the adult form.**

All fields that have a “*” are required. Contact us with any questions regarding the form.


    Concern That Prompted You To Bring Child For Treatment:*

    Where does the problem occur (Check all that apply)?*

    Activity Level:*

    Parents presently married:*

    Parents divorced:*

    Any of the parents deceased (Check all that apply)?*

    Any of the parents remarry (Check all that apply)?*

    Contact with extended family members (Check all that apply)?*