Youth-Intake – I-View Mental Health

Youth Intake

Parents and guardians, please complete the following form for medication management and therapy services. Consent of legal guardian is required to participate. We currently serve children ages 7+ only.

Name of Child

Child Date of Birth

Gender

Male Female Non-Binary

Name of Legal Guardian

Guardian Email

Guardian Phone Number

Full Names of Child's Parents

Street Address

City

Zip Code

Services Requested

Therapy Medication Management

Insurance Carrier

Insurance Member ID

Policy Holder Name

Policy Holder Date of Birth

Secondary Insurance Carrier

Secondary Insurance Policy Holder Name

Insurance Policy holder's date of birth

Insurance Card Images

Current Diagnosis

Current Medications

Treatment History

Have you been court ordered or mandated to treatment by a government agency?

Yes No

If yes, which agency

Are you seeking services related to a legal process such as divorce or custody?

Yes No

Preferred Pharmacy

Current Allergies

Emergency Contact for Child

Emergency Contact Number

Youth Intake

Your Mental Health is Our Priority