Child/ Adolescent Intake form

Nucleus Behavioral Health

First name

Last name

Child's date of birth

Pronouns

Please list grade and school of attendance

Please list any school supports

Has your child ever had therapy before? If yes, with who?

Parent/ guardian 1

Parent/ Guardian name

Occupation

Parent/ guardian home address

Parent/ guardian phone number

Parent/ guardian email

Parent/ guardian 2

Parent/ Guardian name

Occupation

Parent/ guardian home address

Parent/ guardian phone number

Parent/ guardian email

List any siblings and ages

Are there any custody orders in place?

Yes

No

If yes, do you have a copy of the current custody order?

Are you interested in therapy, assessment, or both?

Therapy

Assessment

Both!

Briefly describe your concerns

Are there current concerns related to:

Please list any prescribed medication, supplements, or over the counter medication

Have there been any recent changes in:

If you indicated "other," what has changed for your child recently?

Does your child present with any dietary or feeding concerns?

Yes

No

If "yes," what concerns do you have?

Any access to weapons in the home?

Yes

No

History

Any prenatal difficulty?

Yes

No

If yes, please list any prenatal difficulty

Any delays in development?

Yes

No

If yes, please list any delays

Has your child experienced any of the following medical concerns?

Does your child have any history of:

Insurance

Would you like to see if we can bill your insurance?

Yes

No

While we will do our best to bill your insurance, it is your responsibility to contact your insurance company for information regarding any deductables or copays. If we cannot bill your insurance or your session fees go to your deductable, you will be responsible for the cost of service at the time of the appointment.
Please make sure you inform us of any secondary coverage prior to your first appointment.
Superbills for the cost of service can be provided following payment for each session.

Upload your insurance card here. We will contact your insurance company to verify your coverage.

Please upload the front and back of your insurance card

Thank you for completing this form.

We will reach out to you within 48 hours to discuss scheduling!

Nucleus Behavioral Health

offering in-person and telehealth appointments

Child/ Adolescent Intake Form

Please complete the following so we can get you started!