Please call 815-290-9711 BEFORE completing this form to ensure we can meet your needs and have an opening.
This form should be completed by the guardian of the teen desiring counseling.
If your child was adopted, answer to the best of your ability or write "unknown."
If your teen was adopted, please share the adoption story.
Please describe the child's relationship with the following
Does anyone in the child's immediate or extended family have the following problems (brother, sister, parent, grandparent, aunt, uncle, cousin)?
Please indicate if any of the following have occurred in the family:
Your child intake form has been successfully submitted. Thank you.