1. Cornerstone Intake Form

Cornerstone Intake Form
What services are you seeking?*

Outpatient mental health services (available after school hours at any of our 4 Serenity locations)In-school support services (located within the school, available during school hours)
!!!ATTENTION!!!

You selected Outpatient mental health services, please fill out our standard intake form at

https://form.jotform.com/212315609627152
Student's Preferred Name:*
Legal Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date of Birth
Current*

MonthDayYear
Date of Birth
Age:*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender:*

MaleFemale
Gender Identity:*
Preferred Pronouns:*
Mother's Name: *

FirstLast
Father's Name:*

FirstLast
Guardian's Name:

FirstLast
Sexual Orientation: *
Race:*
Email:
Primary Contact: *

FirstLast
Primary Contact Phone:*

Area CodePhone Number
Emergency Contact:*

NamePhone Number
Okay to leave message?:

YesNo
Relationship to Client?:*

SelfLegal ParentGrandparentFoster ParentStep ParentGuardian
Presenting Concern:
Describe Your Concern:
Describe your current intervention(s); effectiveness and results:
Summary of parent contact/involvement:
Please verify that you are human*
Should be Empty: