Child Intake Form

A. Child/Teen Intake Form

Name of Parent Completing this Form(Required)

First Last

Relationship:

Name of the CFR professional assisting you:(Required)

Amy Armstrong

Wendi Stern

Terri Johnston

Deb Frazier

Brooke Jones

Child's Full Legal Name(Required)

First Middle Last Suffix

Nick Name

First Last

Date of Birth(Required)

Age:

Gender

Child's Cell Phone Number

Parent's Cell Phone Number(Required)

OK to Leave a text?

Yes

No

Child's Email

Child's Address(Required)

Street Address Address Line 2 City State ZIP Code

Are there others living in either of the homes?

Check if applicable

Please List Names, Ages and Relationships

In Case of Emergency

Emergency Contact Name

Emergency Contact Phone

Relationship to the Child

B. Questionnaire

Do the Parents have a shared Parenting Plan?

Yes

No

If "Yes", please provide a copy to your CFR Professional and a brief summary below:

If "No", who has legal decision making for this child?

Is this child currently the subject of a custody dispute?

Yes

No

If "Yes", please explain:

Briefly describe the reason(s) you are seeking coaching for this child:

Goals you would like for your child to achieve through coaching:

A. Child/Teen Intake Form

B. Questionnaire

C. Child Mental Health Profile

C. Child Education Profile

From the Web

Subscribe to our mailing list