New Client Form (Child)

Please fill out all applicable information below. If you prefer to print out and complete a PDF form, you can download it here.

Date

YYYY

Child's Information

Designated Client

For child, parents please fill out information about yourself/selves below

Child's Date of Birth

YYYY

Pediatrician

Psychiatrist

Current Medications

Previous Therapist(s) Seen, When, By Whom:

Emergency Contact / Relationship / Phone #

Parent/Guardian information

Name

First Name

Last Name

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Best Phone # (Home, Work, Cell)

(###)

###

####

Occupation / Employer

Relationship Information

Relationship Status

Children

List all children, age and grade in school

Emergency Contact

First Name

Last Name

Relationship to Emergency Contact

Partner Information

Partner's Name

First Name

Last Name

Best Phone # (Home, Work, Cell)

(###)

###

####

Occupation / Employer

New Client Form (Child)

Linda Wirth, LCSW

Linda Wirth, LCSW