Family Intake Form – Memphis Family Connection Center

Thank you for using this secure form to send your information to our Care Team! We will be in touch within 72 business hours with an appointment time. Please be sure to click “submit” when the form is complete.

Step 1 of 2

Are you filling this form out:*
Please use this section to tell us a bit more about yourself.
- For yourself
- For your family or child(ren)
- As a referral source

Save and Continue Later

Client Information
Name
First Last
Phone
Email
How did you hear about MFCC?
Birthdate
MM slash DD slash YYYY
Do you have health insurance that covers mental health services?
At this time, MFCC is able to bill certain therapeutic services to several insurance panels. For services not covered by insurance, we offer affordable care and a sliding scale. If you have insurance, please list your primary insurance information here, and during the intake process we'll give you further details. Please bring your insurance card to your first appointment.
- Yes
- No
How can we help?
Referral Source
If you are making a referral to MFCC, please list as much information as you can about the client. We will contact you soon.
Name of person completing form
Prefix First Last
Place of Employment
Email
Phone
How did you hear about MFCC?
Primary Caregiver Information
Primary Caregiver Name
Prefix First Last
Date of Birth*
MM slash DD slash YYYY
Relationship to Child
If Other or Kinship, please describe your relationship to the child:
Home Address
Street Address Address Line 2 City State ZIP Code
Best Phone Number
Email Address
How did you hear about MFCC?
Preferred Method(s) of Communication?
- Phone - Call
- Phone - Text
- Email
Place of Employment
Other Adults over 18 living in the home and relationship?
How many children living in home?
Is a Secondary Caregiver present in the child's life?
ex: spouse, step-parent, grandparent, support person, etc...
- Yes
- No
Secondary Caregiver Information
Secondary Caregiver Name
Prefix First Last
Date of Birth
MM slash DD slash YYYY
Relationship to Child
If Other or Kinship, please describe your relationship to the child:
Home Address (leave blank if same as primary caregiver)
Street Address Address Line 2 City State ZIP Code
Best Phone Number
Email Address
Preferred Method(s) of Communication?
- Phone - Call
- Phone - Text
- Email
Place of Employment
Primary Child
While you may have more than 3 children in your home, right now this form only takes info on 3 kids - we can learn more about your family in full when we meet. If you are concerned about a specific child in the home, please use that child as "primary". Thank you!
Name
First Last
Child's Current Age
Birthdate
MM slash DD slash YYYY
Entry into Family
select all that apply
- Adopted
- Foster-to-Adopt (in process)
- Foster Child
- Kinship Placement
- Biological
- Step Child
- Other
If Other, please describe child's entry into family:
If child is in foster care, what is plan going forward?
ex.: Termination of Parental Rights, Reunification, Available for Adoption...
How long has the child been in your home?
Primary Child Educational Status:
Grade in School:
Does the child attend day care?
- Yes
- No
Where does the child attend school/college?
Does the child have specific challenges at daycare/school/college?
Does the child have an IEP in place or receive accommodations at school/college?
- Yes
- No
Any learning disabilities or needs?
Does the child have any specific genetic or medical diagnosis(es)?
Any neurological or psychological diagnosis(es)?
Any special ambulatory needs?
ex: walking, jumping, uses an assistive device just as a wheelchair or braces to move around or walk
Any special ambulatory needs?
Who is the child's primary pediatrician or doctor?
Is the child under the care of any specialists for medical conditions?
Known medicine or environmental allergies?
Current medicines, including vitamins, minerals, herbals or oils?
Any holistic therapies or methods tried thus far (and for how long)?
Any current therapies in place, including frequency?
ex: Occupational Therapy, Physical Therapy, Nutrition, Feeding Therapy, Sensory Therapy
What specific behavior or emotional challenges are displayed in the home?
Nutrition and Eating Habits
Elaborate on the child's food preferences and eating habits. Does he seem to overeat at times? Does she regularly refuse food? Is he on a self-limited diet? If so, what are main foods he or she seems to enjoy?
What type of rest/leisure activities does the child gravitate towards?
ex: legos, TV, reading, video games, trampoline, running, gymnastics-type activities...
What activities, sports, hobbies is the child involved in (if any)?
please elaborate for each child in your home.
Second Child
Name
First Last
Child's Current Age
Birthdate
MM slash DD slash YYYY
Entry into Family
select all that apply
- Adopted
- Foster-to-Adopt (in process)
- Foster Child
- Kinship Placement
- Biological
- Step Child
- Other
If Other, please describe child's entry into family:
If child is in foster care, what is plan going forward?
ex.: Termination of Parental Rights, Reunification, Available for Adoption...
How long has the child been in your home?
Second Child Educational Status:
Grade in School:
Does the child attend day care?
- Yes
- No
Where does the child attend school/college?
Does the child have specific challenges at daycare/school/college?
Does the child have an IEP in place or receive accommodations at school/college?
- Yes
- No
Any learning disabilities or needs?
Does the child have any specific genetic or medical diagnosis(es)?
Any neurological or psychological diagnosis(es)?
Any special ambulatory needs?
ex: walking, jumping, uses an assistive device just as a wheelchair or braces to move around or walk
Nutrition and Eating Habits
Elaborate on the child's food preferences and eating habits. Does he seem to overeat at times? Does she regularly refuse food? Is he on a self-limited diet? If so, what are main foods he or she seems to enjoy?
What type of rest/leisure activities does the child gravitate towards?
ex: legos, TV, reading, video games, trampoline, running, gymnastics-type activities...
What activities, sports, hobbies is the child involved in (if any)?
please elaborate for each child in your home.
Third Child
Name
First Last
Child's Current Age
Birthdate
MM slash DD slash YYYY
Entry into Family
select all that apply
- Adopted
- Foster-to-Adopt (in process)
- Foster Child
- Kinship Placement
- Biological
- Step Child
- Other
If Other, please describe child's entry into family:
If child is in foster care, what is plan going forward?
ex.: Termination of Parental Rights, Reunification, Available for Adoption...
How long has the child been in your home?
Third Child Educational Status:
Grade in School:
Does the child attend day care?
- Yes
- No
Where does the child attend school/college?
Does the child have specific challenges at daycare/school/college?
Does the child have an IEP in place or receive accommodations at school/college?
- Yes
- No
Any learning disabilities or needs?
Does the child have any specific genetic or medical diagnosis(es)?
Any neurological or psychological diagnosis(es)?
Nutrition and Eating Habits
Elaborate on the child's food preferences and eating habits. Does he seem to overeat at times? Does she regularly refuse food? Is he on a self-limited diet? If so, what are main foods he or she seems to enjoy?
What type of rest/leisure activities does the child gravitate towards?
ex: legos, TV, reading, video games, trampoline, running, gymnastics-type activities...
What activities, sports, hobbies is the child involved in (if any)?
please elaborate for each child in your home.
Insurance Information
At this time, MFCC is able to bill certain therapeutic services to several insurance panels. For services not covered by insurance, we offer affordable care and a sliding scale. If you have insurance, please list your primary insurance information here, and during the intake process we'll give you further details. Please bring your insurance card to your first appointment.
Insured Client's Name:
Insured Client's DOB:
MM slash DD slash YYYY
Primary Policy Holder Name:
First Last
Name of Insurance Company:
Member or Subscriber ID:
Effective Date:
MM slash DD slash YYYY
Additional Family Information
Religious Affiliation/Church (if any)?
What types of activities do the parents/primary caregivers in the home participate in for rest/leisure (if any)?
What are your regular family feeding patterns?
ex: dinner regularly together, kids mainly eat lunch and/or breakfast at school, frequent meals out, frequent fast food, on a whole-food diet, low-sugar diet, etc...
Describe the correction methods you use most frequently with the children in your home.
How can MFCC help?
please elaborate on the needs you see in your family.
Phone
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Step 1 of 2

Client Information

Referral Source

Primary Caregiver Information

Secondary Caregiver Information

Primary Child

Second Child

Third Child

Insurance Information

Additional Family Information