Child / Adolescent Intake Form

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Gender *
Parent / Guardian's marital status: *
Married to child's bio mom / dad *
Are you the custodial / decision making parent meaning you have legal documentation stating the other parent does not have this right. OR do you have joint custodial rights and / or decision making authority?
In cases of divorce, separation, or when legal custody is not previously established above, we are required to let both custodial parents / guardians know that the child is in treatment. By selecting this box you are affirming that you are not aware of the whereabouts of the your child's other parent and you've exhausted all attempts to let them know their child is in treatment.
Please attach supporting documentation.  This could include court documents, divorce decree, adoption papers, birth certificate, etc.  If you have any questions, please contact our office at 719-540-2146 before continuing. 

Would you like to add another contact number? *
Best time to call *
Emergency contact information
 NamePhone numberRelationship
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Responsible Financial Party

We require a credit card to be placed on file.  Cards are securely filed and will be used only for payment of co-pays, co-insurance, payments for service and no-show fees.  Credit card information must be entered even if you are not the responsible party.
 
TRICARE Prime and Active Duty Service Member will not be charged a co-pay but must still put card information for any no-show fees. 
Is financial responsibility someone other than the patient? *
Visa
By checking the box below, you agree that we may charge the card provided for the amount owed the day after it is reflected on the account. *

Referral Information

Presenting Problem

Notices

By checking this box, you acknowledge that you have read the notices above. *

Acknowledgement and Signature

By signing this form, you agree that your child will be seen by a provider at the Family Care Center and will become a client of this clinic upon submission of this form. Parents / guardians are responsible for all payments at time of service. Clients who do not show up for this initial appointment or any subsequent follow-up appointments are subject to a $50 no-show fee which must be paid prior to any further appointments being made. Two or more no-shows for an initial appointment can result in child not being accepted as a client. *
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