Registration 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 email our intake team at: DLNewPatientIntake@stanfordchildrens.org or 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

Registration Form

Thank you for completing this form indicating your interest in the Child and Adolescent Psychiatry Clinics at Stanford Medicine Children's Health.

By completing this form, you are indicating your interest in services in our outpatient clinic. Your answers will help guide next steps.

Submission of this form is not a guarantee of ongoing treatment. Many of our clinics are operating near or at capacity with wait times for services. We are working as quickly as possible to be able to offer services to your child.

Once you submit this form, you will receive an email within the next 7-10 business days from our staff to provide additional information regarding availability of services.

If you have questions regarding this form, please email us at NewPatientIntake@stanfordchildrens.org or call our office at 650-723-5511

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.

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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