Youth Participant Intake Form Full Name: Preferred Name: Date of Birth (MM/DD/YYYY): Age: Gender: Male Female Nonbinary Other School Name & Grade: Preferred Language(s): Parent/Guardian Information Full Name of Parent/Guardian: Relationship to Participant: Contact Number: Email Address: Emergency Contact Name & Number: Personal Background Have you participated in therapy or counseling before? Yes No If yes, briefly describe your experience: What challenges are you currently experiencing in school, at home, or in relationships? How do you express your emotions when feeling upset, sad, or angry? What are your favorite activities or hobbies? Do you have a safe space to talk about your feelings? Yes No If no, would you like support in finding one? Yes No Program Goals What would you like to gain from this program? Consent I understand that my participation in this program is voluntary and confidential. Signature of Participant: Date: Parent/Guardian Signature: Date: Parent Intake Form Full Name of Parent/Guardian: Relationship to Child: Date of Birth (MM/DD/YYYY): Contact Number: Email Address: Preferred Language(s): Child Information Child’s Name: Date of Birth (MM/DD/YYYY): Age: School Name & Grade: Emergency Contact Name & Number: Family Dynamics What strengths do you see in your child? What challenges does your child face? How would you describe your current relationship with your child? Have there been significant changes or events in your family’s life? Parenting Goals What would you like to achieve through this program? Consent I understand that this program is voluntary and focuses on improving family dynamics. Parent/Guardian Signature: Date: Submit Intake Form
