Mindful Solutions Logo OFFICIAL 2.png

(Child) Intake Form

Please provide the following information and answer the questions below.

Please note:  information you provide here is protected as confidential information.

May we leave a message?
May we email you?
Gender

*Please note: Email correspondence is not considered to be a confidential medium of communication.

Family History

Are parents divorced?
Is there any significant information about the parents’ relationship or treatment towards the child which might be beneficial in counseling?
Is there anything unusual or stressful about the child’s relationship with the mother?
Is there anything unusual or stressful about the child’s relationship with the father?