Client Intake Form Clients Full Name * First Name Last Name Preferred Name / Nickname Date of Birth * MM DD YYYY Age * Gender * Male Female Prefer not to say Other Diagnosis * Primary Language * Other Languages Spoken Parent / Legal Guardian Information Primary Contact Name * First Name Last Name Relationship to child: * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone Number * (###) ### #### Phone Type: * Mobile Home Other Email * Secondary Contact Name First Name Last Name Relationship to child: Phone Number (###) ### #### Email Emergency Contact Name (Other than Parent / Guardian): * First Name Last Name Relationship to Child: * Phone Number * (###) ### #### Medical Information Primary Care Physician Full Name: * Phone Number (###) ### #### Insurance Provider * Policy / Member Number * Group Number Allergies Medications Medical Conditions Any pets in the house? * Yes No Please specify the type(s) of pet(s) present in the home. Funding Source: * Private Insurance Medi-Cal Regional Center Private Pay Therapy Details Preferred Session Times: * All Available Session Times: * School Attended Grade level Teacher Name Other Services Received: Speech Therapy Occupational Therapy Physical Therapy Counseling Other Permissions Do you consent to photos/videos being taken for treatment documentation purposes? * Yes No Do you consent to photos/videos being taken for internal staff training purposes? * Yes No Signature & Date I certify that the information provided above is true and accurate to the best of my knowledge. I understand that the information I provide will be kept confidential and protected in accordance with HIPAA regulations. I agree to inform Behavia Therapy of any changes. Parent / Guardian Legal Name (Signature) * Today's Date * MM DD YYYY Thank you for completing the Client Intake Form.