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302 E Manchester Blvd #203
Inglewood, CA, 90301
424-241-0164
Inglewood, CA
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Home
Services
The Team
Client Sign Up
Media
Minor Client Info Form
Please complete the form below in order to process services for your child.
Child's Name
*
First Name
Last Name
Child's Age
*
Your Name
*
First Name
Last Name
Your Phone Number
*
(###)
###
####
Your email address
*
Your relationship to the child
*
Biological Mother
Biological Father
Adoptive Parent
Other type of caregiver
Do you have custody of the child?
*
Yes
No
Do you have sole custody of the child?
*
Yes
No
Please provide the first and last name of the other individual holding custody of the child.
First Name
Last Name
Describe the relationship between you and the other parent/caregiver, if applicable.
Married
Separated
Divorced
Very cooperative
Cooperative
Trying
Extremely difficult
Non-existent
Email address of the other caregiver
Phone number of the other caregiver
(###)
###
####
Does the other caregiver know you are seeking services for the child?
Yes
No
Does the other caregiver agree to you seeking services for the child?
Yes
No
How does your child feel about receiving services?
*
In-the-know and excited
In-the-know and resistant
In-the-know and willing
My child has no idea
Who will be paying for services?
*
I will
The other caregiver will
We will split the cost
Thank you!
