Preferred name of the person filling out this form
*
Must be a parent or guardian.
First Name
Last Name
Your Pronouns
Your Legal Name
*
First Name
Last Name
Your Date of Birth
*
MM
DD
YYYY
Email
*
Phone
*
(###)
###
####
Is it ok to leave a voicemail at this number?
*
Preferred communication method
*
Address
*
Crybaby therapists are licensed in Oregon only, meaning all telehealth sessions are available exclusively to clients who are physically located within Oregon at the time of their session. Clients with out-of-state addresses may still receive services; however, they must be present within Oregon state lines during their telehealth appointments.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Your relationship to child seeking services
*
Child's legal name
*
First Name
Last Name
Child's preferred name
First Name
Last Name
Child's pronouns
Child's date of birth
*
MM
DD
YYYY
Please list all names, emails, and phone numbers of responsible adults who will be involved in child/teen’s life and therapeutic care.
• A custodian has the authority to make all major decisions for a child, including education, medical care, and legal rights.
• A guardian's decision-making power is more limited and usually focuses on day-to-day care and welfare.
Are you currently or will you be engaged in custody or legal proceedings?
*
Disclaimer: our establishment does not engage in custody suits or meditation. Under the licenses our clinicians practice we are unable to conduct assessments so If you are seeking services for custody and legal reasons please know we will be unable to support you. Let us know and we will gladly provide you with appropriate recommendations.
How will you be paying for therapy?
*
OHP (CareOregon/Health Share)
Kaiser
I'll pay out-of-pocket.
Name of Person as listed on the insurance card
First Name
Last Name
Date of birth associated with insurance
MM
DD
YYYY
Phone number on file with insurance
(###)
###
####
Address on file with insurance
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
If you do not have your physical Insurance card, please provide your Member ID Number:
What symptoms is your child/teen experiencing?
*
In a few sentences, tell me what prompted you to bring your kid/teen to therapy at this time?
*
Has there ever been any historical abandoned or interrupted attempts of suicide?
*
Is there any active self-harm?
*
Does your child/teen have any current thoughts of death or talk about not wanting to be here?
*
To your knowledge, is your child being bullied?
*
Does your child or teen engaged in any substance or drug use?
*
If yes, please share details.
Has your child been in therapy before?
*
Does your child/teen want to come to therapy or is this at your urging?
*
Are you open to doing joint sessions if I feel they would be beneficial to your teen/child?
*
Therapist Preference
*
Any
Frankie Forrester (All ages in person and telehealth)
Quinn McIntire (All ages in person and telehealth )
Cam Ericksen (14+ telehealth only)
Kennedy Hanson (14+ telehealth only)
In-person sessions vs Telehealth?
*
*Quinn McIntire offers Play Therapy with Minecraft via Telehealth for all ages
What is your youths specific availability for scheduling?
*
How did you hear about Crybaby?
*
Any questions or anything else we should know?
Subject
