Child Intake Packet

Please print the form below, fill it out, and bring it with you to your first appointment.
Child Intake Packet- pdf version.


You may fill the form out online, just use the survey monkey below and submit it when you have completed. There is more than just one page, please click the next button at the bottom of each page of the survey to continue on. Thank you!

If you have not talked with a counselor or with the office staff, please call in after you have completed the intake to set up an appointment with one of our counselors. We may be reached at 563-556-0699.


Once you have completed the CHILD Intake, please fill out the Developmental History Questionnaire as well.

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