Intake Form

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Intake form

To provide you with a more accurate assessment of costs and timelines, we would greatly appreciate it if you could share additional details with us.

Please don't hesitate to reach out at 888-592-8400. We'll gladly walk you through the process and address any questions you may have.

Date of Transport

Child's Name

Date of Birth

Child's Height:

Child's Weight:

Address of Pickup:

Program

Admissions Person

Mother's Name:

Mother's Phone Number:

Mother's Email:

Mother's Address (if different than pickup):

Father's Name:

Father's Phone Number:

Father's Email:

Father's Address (if different than pickup):

Parental Custody:

Has the child been experimenting/using drugs or alcohol? Please describe:

Does the child have a history of physical aggression? With whom? Please describe:

Has the child ever attempted suicide, had suicidal thoughts, or self-harmed (cutting, burning, etc.)?

Has your child been diagnosed with (ADHD, ASD, ODD etc)? If so please describe:

Is your family working with an Education consultant/School District/Therapist? If so who?

If we have questions about this form, who should we contact?

Contact Info

Company

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