Attachment Center of Kansas

Helping Families Build Stronger Connections

General Intake Forms


Complete ALL the information requested on the following forms and bring to the intake session.  If you have scheduled an intake for both yourself and your child, you will need to complete the adult intake form as well as the Billing Agreement and Consent for Assessment.  Complete a release if you want information released and/or obtained from the doctor, medication provider and/or other service providers.   

Child Intake

Adult Intake

Billing Agreement and Consent

Consent for Assessment and Treatment

Policies for the Center

Release for PHI

Privacy Practices (for your records)

Assessment Forms

Download these forms along with the forms above for Intake, complete ALL the information requested and bring to first session.  

Attachment Trauma Intake Checklist

Day in the Life of Your Child

Parent’s Biography (for each adult caretaker in the home)

Parent Strengths and Needs Profile (for each adult caretaker in the home)

RADQ (for children 5 and over) or

Attachment Symptom Checklist for Children under 5 (if child is under 5 or was placed in the home before age 5)

Sensory Assessment

Facts

  • Children and youth suffer more victimization than do adults in virtually every category,with the exception of homicide.  
  • Approximately 25% to 30% of all children in the US will experience a traumatic event by age 16 years.
  • In 2008, over 772,000 children experienced neglect and/or physical, emotional and/or sexual abuse with children in the age group of birth to 7 being at the highest risk.  
  • Approximately 40% of children in the general population and up to 80% of children in fostercare and adoption have an unhealthy attachment style.      
  • One in four girls and one in six boys will be sexually abused before their 18th birthday.  29% of female rape victims in America were younger than eleven when they were raped.