Pre-Registration Intake Interview

Please provide the requested information to the best of your ability.

Items marked with an asterisk (*) are required.

IMPORTANT:

Once you submit the form, you will receive an email with additional information. It will arrive within an hour of your submitting the form. Please remember to check your junk mail or Spam folder if you don't see the email.

Gender
Phone
Is it OK for us to text you at this number?*
Were you directed to seek our services?*
Which court issued the referral?*
Is there an Injunction?*

An "Injunction" may also be called a restraining order or no-contact order.

Has a Guardian Ad Litem been appointed by the court?
Phone
Marital Status

Please add their age and relationship to your children, if any.

Phone

Coparent Gender
Phone
Phone

Information about your Children

Please list any allergies, behavior concerns, or other diagnoses

History

Do you have a history of drug abuse?
Do you have a history of alcohol abuse?
Have you had DCF involved with you or your children?
Is the DCF case currently open or closed?
Do you have a history of sexual abuse, either as an abuser or as a victim?
Do you have a history of domestic violence, either as an abuser or as a victim?
Have you been a victim of, or been charged with stalking or harassment?
How do you currently communicate with your coparent?

Services

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