Patient Information – Child

Today's Date

Child's Full Name

Date of Birth

Primary Parent

Second Parent

Step Parent

Other

Child Resides with

Home Phone Number

Cell Phone Number

Emergency Contact

Phone Number

Relationship of Emergency Contact

How did you hear about Tracy Riley Counseling?

School

Grade

Brief Description of the Presenting Issue/Concern

Therapy can be a powerful force for change. In order for therapy to be most effective, it helps to have a clear and specific goal. You and your child may find it difficult to express your hopes for therapy in the form of a goal, but please make an initial effort, together if possible. We can discuss further as we spend more time together.

Feel free to list more than one goal, if you wish.

What else do we need to know in order to best enjoy this journey with your child?

You can reach Tracy Riley Counseling and JAX Hypnosis by phone at 904-704-2527 or by email through our website’s secured, confidential contact page .