Child Intake Form

Client Information

The following questionnaire is to be completed by the parent or guardian. This form has been designed to provide necessary information to our staff before our initial conference in order to make the most productive and efficient use of our actual time together. As you complete this form, please feel free to add any additional information which you think may be helpful to us in understanding your child. All information provided by you is strictly confidential and will not be released to anyone without your written request.

Person Completing Form*

First Last

Phone*

Email*

Child's Name*

First Last

Child's Date of Birth

Child's Age*

Home Address*

Street Address Address Line 2 City State ZIP Code

How did you hear about us?

1st Parent's Information

1st Parent's Name

First Last

1st Parent's Phone

1st Parent's Address

Street Address Address Line 2 City State ZIP Code

1st Parent's Date of Birth

1st Parent's Marital Status

1st Parent's Gender

Male
Female

2nd Parent's Information

2nd Parent's Name

First Last

2nd Parent's Phone

2nd Parent's Address

Street Address Address Line 2 City State ZIP Code

2nd Parent's Date of Birth

2nd Parent's Marital Status

2nd Parent's Gender

Male
Female

Step Parent or Guardian (If Applicable)

Step Parent or Guardian Name

First Last

Step Parent or Guardian Phone

Step Parent or Guardian Address

Street Address Address Line 2 City State ZIP Code

Step Parent or Guardian Date of Birth

Step Parent or Guardian Marital Status

Step Parent or Guardian Gender

Male
Female

Child Questionnaire

History of problems.

Please describe what concerns you have regarding your child:

How long has the problem existed?

Have there been any significant stressors for the family: losses, births, deaths, moves, hospitalizations, financial problems, in the last several years?

What attempts have been made to resolve the difficulties?

What are you hoping to gain from seeing a counselor?

Child's Symptoms

Select the symptoms and severity the child is currently experiencing.

Sadness or depression

Suicidal thoughts

Sleep problems

Changes in appetite

Weight change

Inability to focus

Obsessive thoughts

Tension and anxiety

Panic attacks

Memory problems

Compulsive behaviors

Feelings of hostility

Acts of violence

Social isolation

Strange thoughts

Stomach aches

Headaches

Bed wetting

Phobias

Self harm

Please describe symptoms or any symptoms not listed:

Parent's Information

Are there any other agencies involved with the family (DCFS, Child Welfare, Courts, etc)?

For Parents who are divorced, please state custody arrangements.

We will need a copy of custody agreements on file.

Is the ex-spouse (biological parent) aware that you are bringing their children for therapy?

Yes
No
Does Not Apply

Mother's Information

Mother's Name

First Last

Mother's Age

Mother's Occupation

Mother's Employment Status

Unemployed
Employed Part Time
Employed Full Time

Mother's Employer Name

Mother's Significant Medical Problems

Mother's serious illnesses, accidents, or surgeries in the past:

Mother's current and past psychiatric treatment or counseling:

Mother's currently prescribed medications:

Mother's current alcohol/drug use (amount, how often, intoxication frequency):

Mother's history of alcohol/drug use:

Mother's history of arrest:

Mother's Primary Care Physician

First Last

Mother's Psychiatrist

First Last

Father's Information

Father's Name

First Last

Father's Age

Father's Occupation

Father's Employment Status

Unemployed
Employed Part Time
Employed Full Time

Father's Employer Name

Father's Significant Medical Problems

Father's serious illnesses, accidents, or surgeries in the past:

Father's current and past psychiatric treatment or counseling:

Father's currently prescribed medications:

Father's current alcohol/drug use (amount, how often, intoxication frequency):

Father's history of alcohol/drug use:

Father's history of arrest:

Father's Primary Care Physician

First Last

Father's Psychiatrist

First Last

Step Parent or Guardian Information

Step parent or guardian Name

First Last

Step parent or guardian Age

Step parent or guardian Occupation

Step parent or guardian Employer Name

Step parent or guardian Employment Status

Unemployed
Employed Part Time
Employed Full Time

Step parent or guardian Significant Medical Problems

Step parent or guardian serious illnesses, accidents, or surgeries in the past:

Step parent or guardian current and past psychiatric treatment or counseling:

Step parent or guardian currently prescribed medications:

Step parent or guardian current alcohol/drug use (amount, how often, intoxication frequency):

Step parent or guardian history of alcohol/drug use:

Step parent or guardian history of arrest:

Step parent or guardian Primary Care Physician

First Last

Step parent or guardian Psychiatrist

First Last

Child's Information

Child Lives With

Child's School

Child's Grade

Child's Teacher

If adopted, does the child know of adoption?

Yes
No

What age was your child at the time of the adoption?

Child's history of psychiatric treatment or counseling:

Does child have a mental health diagnosis?

Child's current or past drug or alcohol use (indicate past or present amount, frequency):

Child's significant medical problems:

Does child have a learning or physical challenge? Please specify.

Child's serious illnesses, accidents, or surgeries in the past:

Child's medications currently prescribed:

Child's Pediatrician

Child's Psychiatrist

Child's Trauma History

Has the child been verbally abused?

Yes, No. Please explain.

Has the child been physically abused?

Yes, No. Please explain.

Has the child witnessed domestic violence?

Yes, No. Please explain.

Does the child have any other stressors or traumas?

Yes, No. Please explain.

Parent or Guradian Signature

I have filled out the intake form to the best of my ability.

Signature*

CAPTCHA

Client Information

1st Parent's Information

2nd Parent's Information

Step Parent or Guardian (If Applicable)

Child Questionnaire

Child's Symptoms

Parent's Information

Mother's Information

Father's Information

Step Parent or Guardian Information

Child's Information

Child's Trauma History

Parent or Guradian Signature

Address

Client Portal

Address

Client Portal

Phone

Email

Phone

Email