The Watson Institute : Intake Form

To request information regarding services for your child through The Department of Psychological Services at the Watson Institute, please complete the form below.

*Please select the services you are interested in:
Wraparound
Evaluations
Medication Management
Social Skills Groups
Therapy
Camp Programs
Testing

Child's Information

*Last Name:

*First Name:

*Middle Name:

Suffix:

SSN:

*Date of Birth:

*Street Address:

*County:

*City:

*State:

*ZIP Code:

*Area:

Mother's Information

Address same as child's

First Name:

Last Name:

Street Address:

City:

State:

ZIP Code:

Home Telephone:

Work Telephone:

Cell Telephone:

Father's Information

Address same as child's

First Name:

Last Name:

Street Address:

City:

State:

ZIP Code:

Home Telephone:

Work Telephone:

Cell Telephone:

Referral Information

Referred By:

Last Psych Evaluation:

Insurance Information

Primary Carrier:

ID#:

Phone:

Employer:

Secondary Carrier:

ID#:

Phone:

Employer:

Medical Assistance:

PCP:

PCP Phone :

*Who does the child live with?
Mom
Dad
Both
Other

*Are there any custody orders pertaining to the child?:

*Please BRIEFLY indicate questions you would like us to answer.

Today's Date :

Child in services with whom? :

School:

School Contact:

School Contact Phone:

We will contact you within 2 business days after receiving your form to discuss your appointment.

-Confidentiality Statement?
All information will be kept confidential. We will not contact any personnel on behalf of your child without written permission from you.

* = Required Field