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THE COPE CLINIC
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CHILD & YOUTH PSYCHOLOGY
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YOUTH INTAKE FORM
Please take the time to fill out our clinic intake form before your first appointment.
Name:
Age:
Date of Birth:
Home Address (Including Postal Code)
Phone Number:
Email
Emergency Contact (caregiver) name, phone number and email:
Referral Source 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.
Have you had direct contact with any social agency or mental health professional (psychologist, psychiatrist, social worker) in the past?
Yes
No
Are you currently taking medication?
Yes
No
Have you taken medication in the past?
Yes
No
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