COUNSELLING INTAKE FORM

Name of Child or Minor
Name of Child or Minor
Name of Parent or Guardian *
Name of Parent or Guardian
Phone *
Phone
Please select all that apply to your child (past or present). *
Confidentiality *
Your child's confidentiality is taken very seriously and will be respected. No information will be released about your child except for in the following circumstances: * If consent is given * If your child's safety or someone else's safety is in question * If there is reason to believe that a child/minor is at risk of being harmed * If your child's file is subpoenaed and required by law