Pediatric Intake Form.

Please have a parent and/or guardian fill out the form if you are 18 years of age or younger. Thank you for taking the time to tell me about yourself. I look forward to meeting you.

Name

First Name

Last Name

My nickname is or I like to be called :

A place where I feel relaxed and peaceful is:

My favorite color is:

Outside of school, my other interests are:

If you could name three things you like about yourself, what would they be?:

Are you a visual person? Can you picture things in your mind? :

If you could change anything about yourself or a situation, what would that be?:

Is there anything else you would like to tell me about yourself?:

Pediatric Intake Form.

The Artful Alchemist