Stanford Child Psychiatry Intake Form

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Please fill out the information below. If you need to come back to the form at a later time, click the "save and return later" button at the end of the form and you will be given a unique code that you will use to access and complete your form. Once you have completed the form, click the submit button at the end of the form. If you have questions regarding this form, please call our office at 650-723-5511.

Si necesita ayuda en español, llame a la clínica al 650-723-5511

Stanford Medicine Children's Health

Child and Adolescent Psychiatry Outpatient Clinic

New Patient Appointment Request Form

Thank you for your interest in the Child and Adolescent Psychiatry Clinics at Stanford Medicine Children's Health. Please take a moment to complete the questions below to help us better understand your child's current needs. By completing this form, you are indicating your interest in services in our outpatient clinic. Your answers will help guide the initial evaluation process.

We are currently operating near or at capacity. One of our staff will be in touch with you to complete the registration process and provide additional information regarding availability of services.

*Please note, if you are interested in Autism Diagnostic Testing or an Eating Disorder Evaluation, these services require a referral from a physician. We do not accept self (e.g., parent/guardian or patient) initiated referrals for these services.. If you would like to pursue one of these services, please discuss this concern with your doctor to determine whether a referral is indicated and have your doctor make a direct referral. Alternatively, you may click here for a list of community resources.

How to complete this form: While completing the form, if you need to take a break and come back to the form at a later time, click the "save and return later" button at the end of the form. You will be given a unique code that you can use to access and complete your form. Once you have completed the form, click the submit button at the end of the form. If you have questions regarding this form, please call or email our intake office at (insert email) / 650-723-5511.

Privacy and confidentiality All existing confidentiality protections under federal and California law apply to information used or disclosed in this form. Patients/guardians may review the Lucile Packard Children's Hospital Stanford and Packard Children's Health Alliance Notice of Privacy Practices. Submission of form is not to be considered an establishment of a therapeutic relationship nor initiation of treatment.

This form is not monitored. If this is a medical emergency, please immediately call your local emergency service number (911 in the U.S.) to get prompt medical attention, or go to your nearest emergency room. For immediate crisis intervention, text 741741 to reach the Crisis Text Line, or dial the National Suicide Prevention Lifeline at 988.

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