THE COPE CLINIC
CHILD & YOUTH PSYCHOLOGY
PARENT INTAKE FORM
Please take the time to fill out our clinic intake form before your first appointment.
Name of Child/Adolescent
Gender of Child
Choose an option
Name of person completing this form
Relationship to Child/Adolescent:
Home Address (Including Postal Code)
Main Phone Number:
Emergency Contact Name and Phone Number
Referral Source Name and Contact Information (if applicable)
Family Physician Name and Contact Information (if different from referral source)
Please check this box if you give permission for us to contact your family physician if needed.
Has your child had direct contact with any social agency or mental health professional (psychologist, psychiatrist, social worker) in the past?
Is your child currently taking medication?
Has your child taken medication in the past?
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