Child Intake Form
 
Client/Child’s Name____________________________   
Date of Birth:_______________ Address_________________________________           City_______________State_______Zip __________ 
Home Phone(____)__________________Current Grade _________ School______________________ 
Emergency Contact __________________________________________________________________                  Name    Relationship    Phone  
Gender of Patient:  Male  Female  Other _____
 
Parent/Guardian 1 Name____________________________ 
Relationship to client: ________________ 
Address _________________________________ City________________State______
Zip __________  Cell Phone (____)__________________________
 Email: ____________________________________ 
 Employer _________________________________  
Work Phone (____)_________________________   
 
Parent/Guardian 2 Name____________________________ 
Relationship to client: ________________ 
Address _________________________________ City________________State______
Zip __________  Cell Phone (____)__________________________
 Email: ____________________________________ 
 Employer _________________________________  
Work Phone (____)_________________________  
 
How did you hear about Mandala Counseling Services? _______________________________________________ 
 
Does your child have spiritual or religious beliefs that we should be aware of?  oYes    oNo            If yes, Where?_____________________________ 
 
Minor/Child Consent: I have legal authority to do all things necessary with regards to seeking therapy/counseling for my child(ren).  I give my permission of treatment for my child(ren) to receive therapy/counseling from Mandala Counseling  Counseling.  I also acknowledge that the above information is correct.   
 
___________________________________________________________________________________________________ Parent/Guardian Signature    Printed Name     Date 
 
___________________________________________________________________________________________________ Parent/Guardian Signature    Printed Name     Date  
 
Parent's Marital Status: 
Marital Status   oMarried    oRemarried     oSingle     oSeparated   If Divorced: date(s) final ___________________     oDivorced    oDivorced/Single    oDivorced/Dating   
Age of child at separation(s)________________ 
 
1.  Who does child talk to when they need positive, emotional support? 
 oMother      oFather      oAdult Relative      oFriend      oSibling      oTeacher      oOther_________________ 
 
2. Has child ever been involved on any of the following services? 
 oSupport Groups   oTreatment Program   oMental Health Counseling   oAnger Mgmt. Classes    oFamily Counseling   oOther_________________ 
 
3. Please list any physical disabilities your child may have.________________________________________ __________________________________________________________________________________________ 
 
4. Please list any medications your child may currently be taking and for what reason. Medication(s)_____________________________________Reason____________________________________ 
 
5. Please list any health concerns you have about your child. ________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________  
  6. Briefly describe your child’s current school experience (i.e. relationship with teachers, grades and school work, concentration, relationship with peers, etc…). ________________________________________________________________________________________________________________________________________________________________________________________________________________________ 
 
7. Briefly describe how your child is currently functioning at home (i.e. relationship with sibling/s, relationship with parent/s, etc…). ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ 
 
8. Briefly describe your child’s current peer relationships (in and outside of school).   ________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________ 
 
9.  As a parent, what do you believe are the greatest challenges for your child currently? ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
 
10. Please list the members of your current household (In order of age).   
Name      Age              Relationship (i.e. mother, step-father, child #)     _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________  
Therapeutic Disclosure - Mandala Counseling  Counseling 
Confidentiality:   The therapeutic relationship is a privileged relationship and the content of all discussions, testing, notes and evaluations are protected. This information can only be released by your signed consent.  In addition, written permission by all participating parties must be granted in order for recording devices to be utilized during counseling sessions.   Exceptions to Confidentiality: While the therapeutic relationship is confidential, the professional standards and Indiana law require these exceptions: a) When physical harm is threatened against another person, b) When physical harm is threatened against one’s self, c) When physical abuse or neglect is directed at a child or adult, d) When records are subpoenaed by a local, state or federal court, e) 

Cancellation Policy:  Cancellations received with less than 24 hours notice will be charged a $50 missed appointment fee.  Unfortunately, because missed appointments cannot be billed to insurance, you are responsible for the full cost of this fee.  Please discuss situations with your therapist that you think warrant further consideration.   
 
Safety Policy:  The use and/or possession of drugs, alcohol, firearms and weapons of any kind are strictly prohibited on any location where therapy sessions are being conducted through Mandala Counseling  Services. Please stay on premises while your child is in sesssion. 
 
I have read, understand and agree to the policies of Mandala Counseling  Counseling provided in this document as they relate to confidentiality, exceptions to confidentiality, cancellation and safety policies.   
 
Parent or Legal Guardian Signature: _____________________________Date____________
 Partner/Spouse of Parent/Guardian Signature (if applicable) _________________________________Date_____________    
  
Acknowledgement-Receipt of Notice of Privacy Practices 
By signing below, I acknowledge that I have received the Notice of Privacy Practices from Mandala Counseling  Services. I am also aware that a Notice of Privacy Practices is obtainable by going to Mandala Counseling ’s website and clicking on the “Intake Forms” link (www.Mandala-counseling.com). Forms are also available on location.  
Parent or Legal Guardian Signature _______________________________________________Date_____________________
 Partner/Spouse or Parent/Guardian Signature _______________________________________________Date_____________        (If Applicable)  
 
Financial Obligation & Fee Policy - Mandala Counseling  Services. LLC 
 
Fee Policy: The initial intake appointment is $180.00 for all new clients.  Beyond that, a typical 50 minute session is $125. However, charges are ultimately subject to the procedure code selected.  . Regardless of negotiated fee arrangements and/or insurance coverage, payment for counseling services is your responsibility and due at the time of your counseling appointment.  If filing with insurance, you are ultimately responsible for any claims not paid by your insurance company for any reason. A No Show fee will be charged at the price of your scheduled session.  
 
Method of Payment: 
_______Self Pay             _____Insurance  

Billable Party:  Who will be responsible for payment of charges not covered by another entity? 
 Billable Party Name: _____________________________________________________
Phone:  _______________________________________________________________ 
Relationship to Client:  _____________________________________________________________________ 
Address:  ________________________________________________________________________                      				City                                                   State            Zip 
   
I have read, understand and agree to the Financial Obligation policies of Mandala Counseling  Counseling provided in this document and authorize Mandala Counseling  Counseling to send correspondence relating to dates of service and charges to the billable party stated above. 
 
Parent or Legal Guardian Signature_______________________________________________Date:____________

Insurance for Mental Health Services- Mandala Counseling  Services
 
Insurance Considerations:  The filing of an insurance claim requires that we provide a diagnosis to your insurance company. There have been occasions when a clinical diagnosis to your insurance has resulted in persons experiencing difficulty in obtaining life, medical or disability insurance. 
 
Insurance Information:  There are numerous insurance companies that offer mental health benefits as part of their coverage. We suggest you check with your insurance provider to determine the requirements for insurance coverage. You will want to ask your insurance company about deductible requirements, authorization requirements, percentage of co-payment, number of sessions per year and “In-Network” vs. “Out-of Network” benefits. Contracting with insurance companies is the decision of each individual therapist.  Mandala Counseling Services will be glad to assist you by providing and filing the necessary information for insurance reimbursement.  Be aware that if you are seeing a provider who is not licensed or out-of network, filing for insurance may not be an option and efforts to obtain reimbursement are provided as a courtesy.  You are ultimately responsible for any charges not covered by insurance for any reason. You are also responsible for notification to Mandala Counseling Services should your insurance coverage change and/or terminate.    
Insurance Pre-Certification/Authorization of Services:  Many insurance companies now require preauthorization of services.  Please know that it is your responsibility to obtain authorization of services for an out-of-network provider if needed.  You will be responsible for any charges not covered by insurance due to lack of precertification/authorization for an out-of-network provider. However, you are ultimately responsible for any charges not covered for any reason.  
 
Authorization to Release Information:  By signing below, I authorize Mandala Counseling  Services, LLC to release my clinical diagnosis, prognosis and treatment request information acquired in the course of my examination or treatment to my insurance carrier.  I am also aware that payment is ultimately my responsibility and should my insurance fail to pay for services for any reason, I am required to pay Mandala Counseling  Services for services and reconciling with insurance is my responsibility. 
 
I have read and understand the policies of Mandala Counseling  Services provided in this document as it relates to filing insurance for mental health services and have provided a copy of my insurance card for filing purposes.   
 
Parent or Legal Guardian of Client Signature ________________________________________________Date____________________