Family Intake Form 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 50% Are you filling this form out:*Please use this section to tell us a bit more about yourself. For yourselfFor your family or child(ren)As a referral source Client InformationName First Last PhoneEmail How did you hear about MFCC?Birthdate Date Format: 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. YesNoHow can we help?Referral SourceIf 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 Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Place of EmploymentEmail PhoneHow did you hear about MFCC?Primary Caregiver InformationPrimary Caregiver Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of Birth* Date Format: MM slash DD slash YYYY Relationship to ChildAdoptive ParentFoster ParentBiological ParentGrandparentKinship Foster ParentGuardian Ad LitemFamily FriendOtherIf Other or Kinship, please describe your relationship to the child:Home Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Phone NumberEmail Address How did you hear about MFCC?Preferred Method(s) of Communication? Phone - Call Phone - Text Email Place of EmploymentOther Adults over 18 living in the home and relationship?How many children living in home?12345678more than 8Is a Secondary Caregiver present in the child's life?ex: spouse, step-parent, grandparent, support person, etc...YesNoSecondary Caregiver InformationSecondary Caregiver Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Date of Birth Date Format: MM slash DD slash YYYY Relationship to ChildSocial WorkerGuardian Ad LitemAdoptive MotherAdoptive FatherFoster MomFoster DadBiological MomBiological DadGrandmotherGrandfatherKinship Foster ParentFamily FriendOtherIf 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Phone NumberEmail Address Preferred Method(s) of Communication? Phone - Call Phone - Text Email Place of EmploymentPrimary 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 AgeBirthdate Date Format: MM slash DD slash YYYY Entry into Familyselect 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:Not yet in schoolhome schooledpublic schoolprivate schoolcollegeGrade in School:Does the child attend day care?YesNoWhere 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?YesNoAny 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 HabitsElaborate 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 ChildName First Last Child's Current AgeBirthdate Date Format: MM slash DD slash YYYY Entry into Familyselect 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:Not yet in schoolhome schooledpublic schoolprivate schoolcollegeGrade in School:Does the child attend day care?YesNoWhere 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?YesNoAny 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 HabitsElaborate 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 ChildName First Last Child's Current AgeBirthdate Date Format: MM slash DD slash YYYY Entry into Familyselect 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:Not yet in schoolhome schooledpublic schoolprivate schoolcollegeGrade in School:Does the child attend day care?YesNoWhere 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?YesNoAny learning disabilities or needs?Does the child have any specific genetic or medical diagnosis(es)?Any neurological or psychological diagnosis(es)?Nutrition and Eating HabitsElaborate 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 InformationAt 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: Date Format: MM slash DD slash YYYY Primary Policy Holder Name: First Last Name of Insurance Company:Member or Subscriber ID:Effective Date: Date Format: MM slash DD slash YYYY Additional Family InformationReligious 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. CommentsThis field is for validation purposes and should be left unchanged.
