Online Intake Form for Child/ Adolescent Online Intake Form for Child/ Adolescents 1. Basic Information Child's Name: Date of Birth: Age: Gender: Parent's Name: Guardian's Name: Relationship to Child: Contact Number: 2. Address Street Address: City: Province: OntarioQuebecNew BrunswickPrince Edward IslandNova ScotiaNewfoundland and LabradorManitobaSaskatchewanAlbertaBritish ColumbiaNorthwest TerritoriesYukonNunavut Postal Code: 3. Emergency Contact Name: Phone Number: 4. Reason for Visit Please describe the main concerns or issues: 5. Medical History Does the child have any medical conditions? Yes No If yes, please specify: Is the child currently taking any medication? Yes No If yes, please specify: 6. Mental Health History Has the child received counselling or therapy before? Yes No If yes, please specify: Any history of mental health diagnoses? Yes No If yes, please specify: 7. Family History Is there a family history of mental health issues? Yes No If yes, please specify: 8. Additional Information Is there anything else you would like us to know? 9. Consent I consent to the assessment and treatment of my child. Parent's Name: Guardian's Name: Signature signature keyboard Clear Date Submit If you are human, leave this field blank. Δ
