Tomaro's C.H.A.N.G.E. - A Nonprofit Organization Providing Therapy, Counseling, & Charity Services in Claymont, DE
  • Welcome to Tomaro's CHANGE!
  • Our Vision
  • Our Services
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  • Contact TC
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  • Welcome to Tomaro's CHANGE!
  • Our Vision
  • Our Services
  • Groups & Classes
  • Our Service Fees
  • Contact TC
  • FAQ
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YOUR CART

Welcome & thank you for choosing me to be your Counselor/Therapist!!! As a representative of The Center for Child Development, I promise to work side by side with you & your child, providing you with quality care & attention, & family centered services that will assist your child in making the desired transition into the next phase of their life. Please note that the Policies & Privacy Practices for TC applies to me, your Counselor/Therapist & the services that I provide.

Tomaro Pilgrim ~ The Center for Child Development
Youth Intake Form ~ Complete, Sign & Submit

​(Must be completed prior to initial meeting!)

    Contact Information


    Child/Adolescent Questionnaire

    Please review the questions below; reflect on the past 2 weeks and complete them to the best of your ability. The information collected will assist your child's counselor/coach in creating a plan that will assist them in your goals. Please take note that there are two sides to the form. If your child is under 12 years of age please complete the 'child' side of the form; if the child is 12 and over please complete the adolescent side of the form.

    Presenting Problems/Concerns

    CHILD ~ Under Age 12

    ADOLESCENT ~ 12 years and older

    Are the child's issues affecting any of the following?

    ​Family & Developmental History


    Medical History


    Substance Use History

    If you answered yes to the above question then please answer the questions below, otherwise proceed to the next section of the intake form. 

    Education

    If you answered yes to the question above, please answer the following questions; otherwise please proceed to the next section. 

    Interpersonal/Social/Cultural Information

    ​​Please click below in order to submit your Intake Form. You will be forwarded to the appointment page!​

SUBMIT ~ I CONFIRM THAT I HAVE READ THE POLICIES & SERVICES, & AGREE TO SERVICES PROVIDED BY TOMARO PILGRIM
POLICIES & PRIVACY PRACTICES
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