Parent (or other person) completing this form: Your name ...

Parent (or other person) BEHAVIORAL. completing this form: SOLUTIONS, PC Intake Form HEALTH. Your name_____. Therapist: & relationship to patient: Date: _____ PTA PE 90847 90806. Referral Information Patient Name: _____ Nickname: _____. Home Address: _____ City: _____ State: ___ Zip: _____. Phone #: _____ May we contact you at this #? Yes No Email:_____. Primary Care Physician: _____ Phone #: _____. Who referred you to this clinic?: _____. Reason for referral? (Please provide a brief description): _____. _____. _____. _____. Insurance Coverage (company(s)): _____. Patient's Background Information / Family Dynamics Date of Birth: Age: Ethnicity (circle all that apply): African-American Asian-American Hispanic Native American Caucasian other : _____. Sex: M F Religious Preference: _____. Patient resides with: Biological Parent (s) Adoptive Parent (s) Foster Parent (s) Legal Guardian(s) other : _____. Persons with whom the child is currently residing Mother's name:_____ Father's name: _____.

Previous residences: City and State Length of Time Lived There Reason for Move

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