Pitts & Associates Child Intake Form 2013-2025 free printable template

Child Intake Form Child s Name (listed on insurance) Child is called: Date of Birth: Social Security Number: Male Female Street Address: City: State: Zip: Phone #1: name listed under? (#1 used for

How to fill out Pitts Associates Child Intake Form

How to fill out Pitts & Associates Child Intake Form

1. Begin by entering the child's full name at the top of the form.
2. Fill in the child's date of birth and age.
3. Provide the child's gender and any preferred pronouns.
4. Complete the address section, including street, city, state, and zip code.
5. Enter the parent's or guardian's contact information, including phone numbers and email address.
6. Include emergency contact details in case the parent/guardian is unavailable.
7. Fill out any relevant medical history sections, noting any allergies or ongoing treatments.
8. Provide information about the child's educational background and current school attendance.
9. List any previous therapies or interventions the child has received.
10. Finally, ensure to sign and date the form, confirming that all information provided is accurate.

Who needs Pitts & Associates Child Intake Form?

1. Parents or guardians seeking assessment or treatment for their child.
2. Therapists and counselors working with children who require background information.
3. Schools needing to understand a child's specific needs or circumstances.
4. Medical professionals referring a child for psychological or behavioral evaluations.

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What is Pitts & Associates Child Intake Form?

The Pitts & Associates Child Intake Form is a document used to collect essential information about a child and their family for various purposes, including assessments, evaluations, and services provided by Pitts & Associates.

Who is required to file Pitts & Associates Child Intake Form?

Parents or guardians of a child who seeks services from Pitts & Associates are required to file the Child Intake Form.

How to fill out Pitts & Associates Child Intake Form?

To fill out the Pitts & Associates Child Intake Form, individuals should provide accurate information regarding the child's personal details, family background, health history, and any relevant concerns or issues that need to be addressed.

What is the purpose of Pitts & Associates Child Intake Form?

The purpose of the Pitts & Associates Child Intake Form is to gather comprehensive information about the child and their circumstances to facilitate appropriate evaluations, planning, and interventions for their needs.

What information must be reported on Pitts & Associates Child Intake Form?

The information that must be reported on the Pitts & Associates Child Intake Form includes the child's name, age, contact information, family details, medical history, developmental milestones, and any specific concerns from the parents or guardians.