testing intake form - Defenders of Children

Name(Required)

First Last

Date of Birth(Required)

Email Address

Phone Number

Gender Identity

Preferred Pronouns

Race/Ethnicity

Black/African American

Latino/Hispanic

White

Asian

Native American

Multiracial

Other

How did you hear about us?

Services Needed(Required)

Legal Intake Form

PLEASE NOTE: All information provided to Defenders of Children through this initial intake form will be kept strictly confidential by Defenders of Children. However, simply completing and submitting this initial intake form will not establish an attorney-client relationship between you and Defenders of Children. By completing and submitting this initial intake form, you are applying for legal assistance from Defenders of Children, not retaining Defenders of Children to assist you.

In what legal area(s) do you want assistance?

Description of legal situation or services requested

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is your address protected?

May we leave a voicemail if we call your phone?

Your relationship to the child(ren)

Child(ren)'s names and DOB

Please list the child(ren)'s name and dates of birth.

Current custody status

Do you have an attorney?

Attorney's name (if applicable)

Opposing Party's Information

Opposing party's (OP) full legal name(Required)

OP's date of birth(Required)

OP's address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

OP's phone number

OP's email

OP's current or last known employer

OP's relationship to you

OP's relationship to child(ren)

Does OP have a criminal/domestic violence history?

If so, explain

Does OP have an attorney?

OP's attorney name, if applicable

Department of Child Safety (DCS) and Law Enforcement Information

Is DCS currently investigating?

Have you contacted the police? If so, which department?

Is there a current court case?

City/County

Case Number

Is there a current Order of Protection?

Do you have ECR?

Maricopa County only

If so, please provide the username and password

Behavioral Health Information

PLEASE NOTE: All information provided to Defenders of Children through this initial intake form will be kept strictly confidential by Defenders of Children.

Please check all that apply

Requesting services for

Are both parents in agreement for therapy services for their minor child(ren)?

If yes, full custody documents and/or divorce degree will be needed along with OOP, if one is in place, to ensure there is a clear understanding of the parent's ability to consent to clinical services

Names and ages of child(ren)

Please list the names and ages of child(ren) if services are being requested for them.

Reason(s) for requesting therapeutic services

Please briefly explain why you are requesting mental health services for yourself and/or your child(ren).

Do you have health insurance?

Please provide the name of your provider

Intake Form

Legal Intake Form

Opposing Party's Information

Department of Child Safety (DCS) and Law Enforcement Information

Behavioral Health Information

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