Intake for Services

This form must be completed by

either parent and/or their counsel

prior to an intake appointment.

MOTHER'S DETAILS

Mother's First and Last Name:

Mother's Phone Number & Email Address:

Mother's Location (City / County):

Mother's Counsel if Applicable:

FATHER'S DETAILS

Father's First and Last Name:

Father's Phone Number & Email Address:

Father's Location (City):

Father's Counsel if Applicable:

DETAILS OF CHILD(REN)

Names & Ages of Child(ren):

Case Number / Judge

What services are you seeking?

Therapy Services

Parenting Time Supervision

Guardian Ad Litem / Parenting Time Coordinator

Any Additional Details?

IF YOU HAVE A SETTLEMENT AGREEMENT OR COURT ORDER FOR SERVICES, PLEASE EMAIL THEM TO BOTH: