Child Information Form

PLEASE COMPLETE THE ENTIRE FORM. PLEASE ALLOW AT LEAST 15 MINS TO COMPLETE IT. YOU WILL NEED TO PROVIDE YOUR INSURANCE INFORMATION SO PLEASE BE PREPARED TO ENTER THAT INFORMATION. ALSO PLEASE SIGN ALL THE CONSENT FORMS AND SIGN AT THE END OF THE FORM.

THANK YOU! Please refer here for our privacy policy.

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

SMS Policy - We use business text to confirm and schedule appointments and for general correspondence and not marketing purposes.

By checking this box, you agree to receive text messages from The Eupatheia Center. You may reply Stop to opt-out at any time!

Email Address *

Date of birth: * +

Gender: *

Height:

Weight:

Grade:

School:

Insurance Information

*

Insurance Member ID:

Group:

Policyholder name if parent:

Primary policy holder D.O.B.: * +

Please enter a credit card that we can keep on file for payments/copays/coinsurance/canceled insurance.

Name on card *

Credit Card Number *

Expiration Date DD/MM *

Zip Code *

Previous Psychological Services

Have you seen a therapist, psychologist or psychiatrist before? *

Yes

No

Who did you see, for how long, why, and what was the outcome/diagnosis? *

Why is the child coming to counseling/a psychologist now? *

How long has the problem lasted? *

Under what conditions does the problem get worse? *

Under what conditions does the problem get better? *

Family Situation

Home Environment: *

People living in the home:

	Name	Role (mother/brother/stepsister etc)	Age
Person 1	Name	Role (mother/brother/stepsister etc)	Age
Person 2	Name	Role (mother/brother/stepsister etc)	Age
Person 3	Name	Role (mother/brother/stepsister etc)	Age
Person 4	Name	Role (mother/brother/stepsister etc)	Age
Person 5	Name	Role (mother/brother/stepsister etc)	Age
Person 6	Name	Role (mother/brother/stepsister etc)	Age

Are both parents/guardians working? *

Yes

No

Occupations:

Is there any history of physical, verbal, sexual abuse: *

Yes

No

If yes, please explain (all information is confidential and meets HIPAA requirements) *

PRIVATE/SELF-PAY	BCBS/Anthem	Cigna
United Healthcare	Aetna	UMR
Peachstate/Centene	Caresource	First Health Network
Straight Medicaid	Amerigroup	Ambetter
Medicare	Humana	Tricare
Optum Health	EAP	Other Other

Married	Divorced	Single Parent Mother	Single Parent Father
Stepparent	Grandparents	Other Family Member	Other