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INTAKE FORM CHILD / ADOLESCENT Wellness Associates, PC AMANDA J. HUDDLESTON, LCSW (Phone) 574.635.5826 (Fax) 5742871667 ! Identifying Information for client (Child): Date: Driver's License # (Parent)
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How to fill out intake form - child

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How to fill out intake form - child:

01
Start by carefully reading the instructions provided on the form. Make sure you understand all the sections and requirements before proceeding.
02
Begin by filling out the basic information section. This typically includes the child's name, date of birth, gender, and contact details. Provide accurate and up-to-date information to ensure effective communication.
03
Move on to the medical history section. Here, you will need to provide details about the child's current and past medical conditions, any allergies they may have, and medications they are currently taking. Be thorough and provide as much information as possible to provide a comprehensive overview of the child's health.
04
Next, you will come across the section for immunization records. It is important to have your child's immunization records handy to accurately fill out this section. Include the types of vaccines received, dates administered, and any additional notes required.
05
Alongside the medical information, the form may also request details about the child's developmental milestones and growth parameters. This can include information about their height, weight, and any significant developmental milestones achieved within a certain age range.
06
If applicable, you may need to provide details about any ongoing therapies or treatments the child is receiving. This can include occupational therapy, speech therapy, or any other specialized care they are undergoing.
07
Some intake forms may ask for information regarding the child's educational background or activities. Be prepared to provide details about their school, grade level, and any extracurricular activities they participate in.
08
Finally, review the completed form to ensure all information is accurate and complete. Double-check for any missing sections or errors.

Who needs intake form - child?

Parents or legal guardians of a child may be required to fill out an intake form for various purposes. These can include enrollment in educational institutions, admission to healthcare facilities, participation in extracurricular activities, or seeking specialized services such as counseling or therapy. The intake form helps gather essential information about the child's background, medical history, and any specific requirements they may have. This information is crucial for developing an understanding of the child's needs and ensuring appropriate care or support is provided.

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