New Client Forms — Children & Teens
From puppets and play to games and growth, we meet each young person exactly where they are.
New Client — Child or Teen Under 18
Start Here. These Are the Forms You Need.
The Quick Form covers most of the intake in one go. Start with Forms 1 and 2 — those two are enough to get your first appointment scheduled. You do not need to finish everything in one sitting.
About the No Surprise Act notice further down this page: that is a separate federal notice for families paying without insurance. It is not a substitute for the forms above, and completing it alone will not start your child’s care.
If custody is set by court order, please also send us the Court Ordered Custody Agreement with Parenting Plan before the first appointment.
Prefer to print and write by hand, or need a school release? Jump to all forms and PDF downloads.
Not sure which form applies to your family? Email DrDarleen@orchardhumanservices.org and we will walk you through it.
Welcome, Parents and Caregivers
Seeking professional support for your family is a meaningful decision, and we honor the care and thoughtfulness that bring you here. Your young person will be met with warmth, clinical skill, and deep respect for their stage of development.
When a teenager reaches adulthood, they can continue independent clinical care with a therapist who already knows their story.
How We Approach Therapy
A developmentally-informed, relationship-centered framework.
Developmentally-Informed
Every stage of development calls for a different approach. We meet each young person at their level, using play-based strategies with our youngest clients, creative and experiential methods mid-range, and a more collaborative therapeutic relationship as maturity develops.
Attachment & Relationship-Centered
Healing happens in safe relationships. Our therapists take the time to build genuine trust with each client, because the therapeutic relationship itself is the most powerful tool we have. Dr. Darleen specializes in attachment-informed care, which shapes every aspect of how we support young people.
Brain-Based & Informed
Behavior is often a window into how the brain and nervous system are responding to stress or developmental demands. Rather than simply managing symptoms, we work to understand the underlying causes and teach the skills that help young people regulate, connect, and thrive.
Family-Involved
Parents and caregivers are partners in the healing process. We keep you informed, coach you through challenges, and support the whole family system. Growth happens within the loving relationships that surround each young person.
What We Help With
Specialized clinical care across neurodevelopmental, emotional, and relational needs.
Neurodevelopmental
Autism Spectrum Disorder (ASD, Asperger’s), ADD and ADHD, Sensory Processing Disorder, Intellectual Disability, Traumatic Brain Injury, Learning Problems, Memory Challenges, Focus and Attentional Challenges
Attachment & Complex Needs
Reactive Attachment Disorder (RAD), Disinhibited Social Engagement Disorder (DSED), Complex Presentations, Developmental Needs, PTSD, Adoption and Foster Care transitions
Mood & Anxiety
Bipolar Disorder, Depression, OCD, ODD, Anxiety and Fear
Severe Symptoms & Safety
Dissociative Disorder, Eating Disorder, Self-Regulation Challenges
School & Learning Support
IEP and Section 504 Plan Advocacy, Learning Disabilities, Academic Performance, Behavior and Classroom Challenges, Autism Socialization, Following Rules and Paying Attention
Parents Are Partners
Your Role in the Healing Process
We believe that parents and caregivers are essential partners in therapeutic work. You know your young person better than anyone — your insights, observations, and care are irreplaceable.
Expect to be included: parent meetings, progress updates, practical strategies to use at home, and support as you navigate this meaningful work together.
All Forms for Children & Teens
Everything available on this page, in the order most families need it.
This page is for clients under 18. If you are seeking services for yourself as an adult, please visit the forms page for adults.
Required for Everyone — Easiest Route
1. Quick Form — All-in-One Intake
Complete the intake in one process. You may be asked to upload additional information separately. Most families only need these two.
Alternative Route
2. Individual Forms, One at a Time
If you would rather complete each form separately, or your clinician has asked for more detail.
Authorization to Treat a Minor
HIPAA Privacy Form
Telemental Health Permission
Consent for Third Party Billing — only if insurance is paying
Appointment Policy
Or download and print
Minor Intake Form (PDF)
Authorization to Treat a Minor (PDF)
HIPAA Privacy Form (PDF)
Telemental Health Permission (PDF)
Consent for Third Party Billing (PDF)
Return completed PDFs to Forms@OrchardHumanServices.org or fax to (877) 660-8884.
Required If Custody Is Court-Ordered
3. Court Ordered Custody Agreement
If custody has been determined by court order, please send a copy of the Court Ordered Custody Agreement with Parenting Plan before the first appointment. This ensures we have appropriate permission to provide services and honor the legal framework protecting your family.
Email it to Forms@OrchardHumanServices.org. Our staff can answer any questions about this requirement.
Self-Pay Families Only
4. No Surprise Act Notice & Consent
This applies only if you are paying for care without insurance. Federal law gives you the right to know what care will cost before it begins. This does not replace the intake forms above.
Complete the Notice & Consent online
Disclosure Statement (PDF)
Full Notice & Consent packet (PDF)
Only If It Applies to You
5. Release Forms
To let us share information with your pediatrician, another provider, or your child’s school.
Authorization & Release Form — pediatrician, providers, individuals
FERPA Release Form — schools and teachers
Fees, insurance, and low-cost options are set out on the fees page, or ask our staff and we will talk it through with you.
If Your Family Needs Help Right Now
Orchard is not a crisis service. If your child is in danger, call 911 or go to the nearest emergency room. Call or text 988 for the Suicide and Crisis Lifeline, any hour.
For non-emergency resources, call (888) 263-1986 and our system will text you support resources and referrals. Your information is confidential.
We Are Honored to Walk Alongside Your Family
Each client is met with care, skill, and deep respect.
Orchard Human Services, Inc.
An IRS-approved 501(c)(3) nonprofit organization, uplifting lives by counseling, educating, and caring.
DrDarleen@orchardhumanservices.org
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