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 NEW LIFE CHRISTIAN COUNSELING CENTER

CLIENT INTAKE FORM - CHILD BC

 

 

CHILD’S NAME ___________________________________________________________________________________________________

                                                Last                                                         First                                                         Middle

 

DATE OF BIRTH ___________________       (   )MALE   (   )FEMALE            SCHOOL __________________________________________        

 

MOTHER’S NAME __________________________________________________________________________________________________

                                                Last                                                         First                                                         Middle

 

MOTHER’S DATE OF BIRTH _____________________   CELL PHONE____________________ WORK PHONE_____________________

 

 

FATHER’S NAME ___________________________________________________________________________________________________

                                                Last                                                         First                                                         Middle

 

FATHER’S DATE OF BIRTH ______________________  CELL PHONE___________________   WORK PHONE_____________________

 

 

THIS CHILD PRIMARILY LIVES WITH: (please circle)  .....Mother & Father   ........Mother only     .........Father only   .......Father & Other

.....Mother & Stepfather       .......Father & Stepmother      .......Mother & Other      50/50 custody......    Other Arrangement  (Please identify)____

___________________________________________________________________________________________________________________

 

and THIS ADDRESS IS__________________________________________________________________________________   ZIP__________

(If 50/50 living arrangement, enter Mother’s information here and Father’s at # 1 below.

                

OR, if custody is other than 50/50, please enter the primary residence information here and state whether this is ….Mother’s......or Father’s...... residence.  (Please circle.)  Enter the secondary/other party’s address at #1 below.       

 

IF CHILD LIVES IN THE SAME HOUSEHOLD WITH BOTH PARENTS, PLEASE SKIP TO *** BELOW, thanks.

 

Otherwise, PLEASE RESPOND TO NUMBERS 1-4 WHERE APPLICABLE:

 

#1.  IN THE CASE OF 50/50 LIVING ARRANGEMENT, you have entered the mother’s information above, please enter the father’s address and best phone number here, and then skip to *** below:

     

      ______________________________________________________________________________________________________________

                                              FATHER’S ADDRESS                                                                                           BEST PHONE NUMBER

            (Or Secondary Address in case of other than 50/50 living arrangement)                                             

 

     #2.  IF BIOLOGICAL PARENTS ARE NOT LIVING TOGETHER, WHO HAS PRIMARY CUSTODY? ____________________________    

    # 3.  IF CHILD PRIMARILY LIVES WITH MOTHER & STEPFATHER OR OTHER, please enter the stepfather’s/other’s name here:

          _____________________________________________________________________________________________________________

 

     #4.  IF CHILD PRIMARILY LIVES WITH FATHER & STEPMOTHER OR OTHER, please enter the stepmother’s/other’s name here:

          _____________________________________________________________________________________________________________

 

 

***PEDIATRICIAN’S OR FAMILY DOCTOR’S NAME ________________________________________PHONE_____________________

 

                                                                               

IF WE ARE FILING INSURANCE FOR YOU, PLEASE COMPLETE THE FOLLOWING:

 

POLICY HOLDER’S NAME___________________________________   and his/her DATE OF BIRTH___________________

 

SOCIAL SECURITY NUMBER OF POLICY HOLDER__________________________________________________________