PLEASE READ BEFORE MOVING TO NEXT PAGE!

Please Note: We recently had a significant increase in demand for our services, and this has forced us to make the tough decision to make changes to our referral process. First, we are no longer taking referrals and requests for services from parishes outside of Louisiana Region 7 (Bienville, Bossier, Caddo, Claiborne, DeSoto, Natchitoches, Red River, Sabine, Webster). Furthermore, we have also made the difficult decision to restrict our services to those children between the ages of 2-12 years. Finally, we anticipate an extended wait time for all new parent intake forms. We are reviewing all requests on a first come, first serve basis. At this time, estimated wait time is approximately 1 - 2 months, from the date you complete this online form. We apologize for any inconvenience these changes may cause.

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The Children's Center Parent Intake Form has been moved to to a new location, please use this form:

https://forms.lsuhs.edu/Forms/Children's-Center-Parent-Intake-Form

Thank you,
LSUHS IT Support
318.675.6506

Children's Center Parent Intake Form

THIS FORM IS FOR CC INFORMATIONAL PURPOSES ONLY. 

THIS IS NOT THE REFERRAL PACKET. PEDIATRICIANS/PCPS ARE REQUIRED TO SUBMIT A SEPARATE PRESCRIPTION/REFERRAL.  

     ATTENTION PLEASE READ!

Please Note: We recently had a significant increase in demand for our services, and this has forced us to make the tough decision to make changes to our referral process. First, we are no longer taking referrals and requests for services from parishes outside of Louisiana Region 7 (Bienville, Bossier, Caddo, Claiborne, DeSoto, Natchitoches, Red River, Sabine, Webster). Furthermore, we have also made the difficult decision to restrict our services to those children between the ages of 2-12 years. Finally, we anticipate an extended wait time for all new parent intake forms. We are reviewing all requests on a first come, first serve basis. At this time, estimated wait time is approximately 1 - 2 months, from the date you complete this online formWe apologize for any inconvenience these changes may cause.

Child's Name*
Date of Birth*
Insurance*

Has child received any previous assessment or currently receiving ongoing treatment?

Early Steps?*
Children's Center*
Other Psychological?*
School (Pupil Appraisal?)*
Other*

CONTACT INFORMATION

Caregiver Name*
Current Street Address*
Does your child have a current diagnosis?*
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