Getting started

Client Intake Form

Welcome to Compassionate Connections Family Services. Please complete this intake form as thoroughly as possible. All information is kept strictly confidential and used only to coordinate your services.

Fields marked * are requiredOne-time intake fee required to begin services

Parent / Guardian 1 (Primary Contact)

First Name*

Last Name*

Date of Birth*

Phone Number*

Email Address*

Street Address

City, State, Zip

Parent / Guardian 2 (Other Parent)

First Name

Last Name

Date of Birth

Phone Number

Email Address

Street Address

City, State, Zip

Children's Information

Please list all children who will be involved in visits or exchanges.

Child 1

Full Name

Date of Birth

Gender

Child 2

Full Name

Date of Birth

Gender

Child 3

Full Name

Date of Birth

Gender

Child 4

Full Name

Date of Birth

Gender

Court Order Information

County*

Case Number*

Presiding Judge

Order Date

Service Type Ordered*

Supervision Level

Special Conditions or Restrictions

List any conditions specified in the court order (e.g. no discussion of case, no recording, specific topics to avoid).

Attorney & Guardian ad Litem (GAL)

Attorney Information

Attorney Name

Firm / Organization

Phone

Guardian ad Litem (GAL) Information

GAL Name

Phone

Scheduling Needs

Desired Start Date*

Visit Frequency

Preferred Days

Preferred Time of Day

Visit Duration

Scheduling Notes

Any additional scheduling constraints, transportation needs, or special considerations.

Additional Information

Anything else you'd like us to know?

Share any context that would help us serve your family well.

Acknowledgment

By submitting this form, I acknowledge that a one-time, non-refundable intake fee of $50 is required before services begin. I understand that full payment must be received at least 24 hours before each scheduled service to avoid cancellation. Invoices are issued via PayPal every Sunday and are due upon receipt. I confirm that the information provided above is accurate to the best of my knowledge.

Questions? Call us at (360) 520-7482 or email [email protected]