Client Intake Form Clients Full Name * First Name Last Name Preferred Name / Nickname Date of Birth * MM DD YYYY Age * Gender * Male Female Prefer not to say Other Diagnosis * Primary Language * Other Languages Spoken Parent / Legal Guardian Information Primary Contact Name * First Name Last Name Relationship to child: * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Phone Type: * Mobile Home Other Email * Secondary Contact Name First Name Last Name Relationship to child: Phone Number (###) ### #### Email Emergency Contact Name (Other than Parent / Guardian): * First Name Last Name Relationship to Child: * Phone Number * (###) ### #### Medical Information Primary Care Physician Full Name: * Phone Number (###) ### #### Insurance Provider * Policy / Member Number * Group Number Allergies Medications Medical Conditions Any pets in the house? * Yes No Please specify the type(s) of pet(s) present in the home. Funding Source: * Private Insurance Medi-Cal Regional Center Private Pay Therapy Details Preferred Session Times: * All Available Session Times: * School Attended Grade level Teacher Name Other Services Received: Speech Therapy Occupational Therapy Physical Therapy Counseling Other Permissions Do you consent to photos/videos being taken for treatment documentation purposes? * Yes No Do you consent to photos/videos being taken for internal staff training purposes? * Yes No By checking this box, I consent to receive text messages from Behavia Therapy related to scheduling, appointment reminders, and service updates. Message frequency may vary. Message and data rates may apply. I understand that I can reply STOP at any time to opt out or HELP for assistance. SMS consent is not shared with third parties or affiliates. For more information, please review our Privacy Policy and Terms of Use. SMS Consent * Yes No Signature & Date I certify that the information provided above is true and accurate to the best of my knowledge. I understand that the information I provide will be kept confidential and protected in accordance with HIPAA regulations. I agree to inform Behavia Therapy of any changes. Parent / Guardian Legal Name (Signature) * Today's Date * MM DD YYYY Thank you for completing the Client Intake Form.
