New Patient Intake Packet

Stoughton Counseling, Inc.

1044 Central St.

Stoughton MA 02072

781.975.2185

Instructions: Please fill out this form completely prior to your first session. This information is confidential and will help us better understand your child's needs.

Child Information

Full Name:

Date of Birth:

Age:

Home Address:

School Name:

Grade:

Parent/Guardian Information

Parent/Guardian 1 Name:

Relationship:

Phone Number:

Email Address:

Parent/Guardian 2 Name:

Relationship:

Reason for Seeking Counseling

Please describe the primary concerns bringing you in today:

When did these concerns begin?

Medical & Mental Health History

Has your child previously received counseling or psychiatric care? (If yes, please describe):

Is your child currently taking any medications? (Please list):

By signing below, I certify that the information provided is accurate to the best of my knowledge and I consent to the evaluation and treatment of the minor child named above.

Parent/Guardian Signature:

Date: