online-intake-form - Wecome to Center for Youth & Family Solutions

Online Intake form

Please complete the following intake information below if you are interested in receiving services from our skilled therapists, and someone will reach out to you to complete the intake process.

Date

Information of person to receive services

First Name

Last Name

Pronouns

He / Him / His She / Her / Hers They / Them / Theirs Something Else

If the previous answer is "Something Else", what pronoun do you prefer?

Street Address

City

State

ZIP

Country

OK to send mail to this address?

Yes No

Please provide the best phone number to reach you at.

OK to leave messages at this phone number?

Yes No

Email Address

OK to send email?

Yes No

Information of person to receive services continued

Date of Birth

Age

Parent/Guardian Information (if individual receiving services is a minor)

First Name

Last Name

Parent/Guardian Street, City, and State (*if different then minor or put 'same address') If not applicable put NA

Street Address

City

State

ZIP

Country

Insurance Information

Insurance / EAP Medicaid None

Availability for Appointment Time

Preference of Modality

In Person Telehealth (video, phone)

Referral Source

Reason for Seeking Services

Submitted!

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