Clinical Intake Application

 

Clinical Intake Form

General Information


Parent / Guardian Information

*If a parent is to be excluded, the custodial parent MUST provide court documentation

Father's Information

*If a parent is to be excluded, the custodial parent MUST provide court documentation

Mother Information


Insurance Information

Medical Insurance Information

Referrals

Please List the names of source(s) through which you heard about the Good Shepherd Catholic School.


Additional Required Information

Please answer the following questions about your child. The information given will be used to better understand your child's history and past performance. The information given is considered to be confidential information, and this information will become part of the client's permanent record file. Additional sheets may be used if necessary.


Siblings


Academic Information

Please list all of the schools your child has attended.


Testing History

Please provide information on all professional assessments or evaluations that your child has received. For each assessment listed below, please submit a complete copy of the written report with this application.

We/I confirm that the information in this application is accurate and complete. We/I grant permission to the Good Shepherd Catholic School and Clinic to obtain any information deemed necessary to complete the application/intake process. This includes, but is not limited to, information from previous schools, service providers or any other individuals that may have knowledge useful to the admissions process. We/I understand that false, misleading, or omitted information provided in this application may result in a denial of services.


Admission Policy

It is our intention to accept clients who can be well served by our program. The Good Shepherd program applies all policies and procedures, equally to all clients and does not discriminate on the basis of race, religion, socio-economic status, sexual orientation, or national or ethnic origin. Application Review will begin when the intake form is complete.