Intake Form Step 1 of 7 14% Intake FormThank you for using our secure form to send your information to our Care Team. We will be in touch within 2-3 business days with information about your next steps! We look forward to beginning this journey together. Note: If you or your loved on are in crisis or in need of immediate mental health assistance please reach out to a local crisis hotline. Please be sure to click “submit” when the form is complete. Step OneName* First Last Phone*Email* Occupation* Place of Employment* How did you hear about MFCC? Are you looking for:* Individual/Couples Services Child/Adolescent/Family Services Individual/Couples Services For YourselfAddress* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* 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 some insurance panels. For services not covered by insurance, we offer high quality affordable care at $85/session. 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 Name of Insurance Provider Are you or any member of your family impacted by adoption, foster care, or child welfare? If so, please explain?*If no, please say n/aHow can we help you?* Are you filling this out for: Your family or child(ren) As a referral source Child/Adolescent/Family Services For Your Family or Child(ren)Primary Caregiver’s Date of Birth* MM slash DD slash YYYY Primary Caregiver’s Relationship to the child*Biological ParentAdoptive ParentFoster ParentGrandparentKinship ParentOtherPrimary Caregiver’s Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code 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. If you have insurance, please list your primary insurance provider here, and during the intake process we’ll give you further details. Please bring your insurance card to your first appointment. Yes No Name of Insurance Provider Is a secondary caregiver present in the child’s life? ex: spouse, partner, grandparent, support person, Yes No Secondary Caregivers’ Name* First Last Secondary Caregiver’s Relationship to the child* Secondary Caregiver’s Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Secondary Caregiver’s Phone Number*Secondary Caregiver’s Email* Secondary Caregiver’s Occupation* Secondary Caregiver’s Place of Employment* How many children living in your household?12344+Child's Name* First Last Child’s Current Age* Birth Date* MM slash DD slash YYYY Entry Into Family*Select all that apply Biological Adoption Foster Care Kinship Step Other At what age did the child come into your care?*Ex: birth, age 2, etc Where does the child attend school? Does your child have any diagnosis(es), disabilities, or ambulatory needs?*Child’s Primary Doctor?* Any additional specialists?* Any known medical or environmental allergies?*If none write “no” Current medications, including vitamins, herbals or oils?Any current therapies in place? If so, what type, how long and how frequent?*Ex: OT, PT, nutrition, feeding, etc What specific behavioral or emotional challenges are you concerned about?* What types of rest/leisure activities or hobbies does your child gravitate towards?* What specific food related behaviors or eating habits, if any, are you concerned about? Child Two's Name* First Last Child Two’s Current Age* Child Two's Birth Date* MM slash DD slash YYYY Entry Into Family*Select all that apply Biological Adoption Foster Care Kinship Step Other At what age did the child come into your care?*Ex: birth, age 2, etc Where does the child attend school? Does your child have any diagnosis(es), disabilities, or ambulatory needs?*Child’s Primary Doctor?* Any additional specialists?* Any known medical or environmental allergies?*If none write “no” Current medications, including vitamins, herbals or oils?Any current therapies in place? If so, what type, how long and how frequent?*Ex: OT, PT, nutrition, feeding, etc What specific behavioral or emotional challenges are you concerned about?* What types of rest/leisure activities or hobbies does your child gravitate towards?* What specific food related behaviors or eating habits, if any, are you concerned about? Child Three's Name* First Last Child Three’s Current Age* Child Three's Birth Date* MM slash DD slash YYYY Entry Into Family*Select all that apply Biological Adoption Foster Care Kinship Step Other At what age did the child come into your care?*Ex: birth, age 2, etc Where does the child attend school? Does your child have any diagnosis(es), disabilities, or ambulatory needs?*Child’s Primary Doctor?* Any additional specialists?* Any known medical or environmental allergies?*If none write “no” Current medications, including vitamins, herbals or oils?Any current therapies in place? If so, what type, how long and how frequent?*What specific behavioral or emotional challenges are you concerned about?*What types of rest/leisure activities or hobbies does your child gravitate towards?*What specific food related behaviors or eating habits, if any, are you concerned about?Child Four's Name* First Last Child Four’s Current Age* Child Four's Birth Date* MM slash DD slash YYYY Entry Into Family*Select all that apply Biological Adoption Foster Care Kinship Step Other At what age did the child come into your care?*Ex: birth, age 2, etc Where does the child attend school? Does your child have any diagnosis(es), disabilities, or ambulatory needs?*Child’s Primary Doctor?* Any additional specialists?* Any known medical or environmental allergies?*If none write “no” Current medications, including vitamins, herbals or oils?Any current therapies in place? If so, what type, how long and how frequent?*What specific behavioral or emotional challenges are you concerned about?*What types of rest/leisure activities or hobbies does your child gravitate towards?*What types of rest/leisure activities or hobbies does your child gravitate towards?*What specific food related behaviors or eating habits, if any, are you concerned about?Please tell us about any additional children in your familyWhat types of activities does your family enjoy doing?*Describe the correction methods you use most frequently with your child(ren)?*How can MFCC help you?* Child/Adolescent/Family Services as a Referral SourceIf you are making a referral to MFCC, please list as much information as you can.Name of Child* First Last Child’s Date of Birth* MM slash DD slash YYYY Your Relationship to Child/Family* Primary Caregiver’s Name* Primary Caregivers Phone*Primary Caregiver’s Email* Primary Caregiver’s Occupation Primary Caregiver’s Place of Employment Primary Caregiver’s Relationship to Child*Biological ParentAdoptive ParentFoster ParentGrandparentKinship ParentOtherFamily/ Child’s Home Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Are there other children in the family? If so, please list names and ages.How can MFCC help?* SubmitOnce you submit the intake form someone from our Care Team will be in touch within 2-3 business days to schedule an Intake Appointment with the parent/caregiver. Our Intake Appointments are a safe place for our team to get to know the needs of the child and family. Once that initial appointment is complete the team creates a unique care plan that is designed to provide an integrated holistic path toward healing. The initial intake appoints are self pay at $35/appointment. NameThis field is for validation purposes and should be left unchanged.