Adolescent Counseling Consent and Intake Form

Adolescent Information

Full Name Date of Birth Age School/Grade Address Phone Email Preferred Pronouns

Parent/Guardian Information

Parent/Guardian Name(s) Relationship to Adolescent Parent/Guardian Phone Parent/Guardian Email

Consent

I/We give consent for my child/adolescent to participate in counseling services. Yes No

Presenting Concerns

Please describe the main concerns or reasons for seeking counseling

Family & Medical Information

Are there any significant medical issues, diagnoses, or medications? Family members in the household

Emergency Contact

Name Relationship Phone Number

Signatures

Parent/Guardian Signature Date