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Child and Adolescent Intake
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Child and Adolescent Intake
Child and Adolescent Intake
For Ages 4 & Up
CHILD INFORMATION
Child's Name
Date of Birth
Address
City
State
Alabama: AL
Alaska: AK
Arizona: AZ
Arkansas: AR
California: CA
Colorado: CO
Connecticut: CT
Delaware: DE
Florida: FL
Georgia: GA
Hawaii: HI
Idaho: ID
Illinois: IL
Indiana: IN
Iowa: IA
Kansas: KS
Kentucky: KY
Louisiana: LA
Maine: ME
Maryland: MD
Massachusetts: MA
Michigan: MI
Minnesota: MN
Mississippi: MS
Missouri: MO
Montana: MT
Nebraska: NE
Nevada: NV
New Hampshire: NH
New Jersey: NJ
New Mexico: NM
New York: NY
North Carolina: NC
North Dakota: ND
Ohio: OH
Oklahoma: OK
Oregon: OR
Pennsylvania: PA
Rhode Island: RI
South Carolina: SC
South Dakota: SD
Tennessee: TN
Texas: TX
Utah: UT
Vermont: VT
Virginia: VA
Washington: WA
West Virginia: WV
Wisconsin: WI
Wyoming: WY
Zip
SSN
Last grade completed in school
Grade Average
Name of School
MOTHER'S INFORMATION
Name
Date of Birth
SSN
Address
City
State
Alabama: AL
Alaska: AK
Arizona: AZ
Arkansas: AR
California: CA
Colorado: CO
Connecticut: CT
Delaware: DE
Florida: FL
Georgia: GA
Hawaii: HI
Idaho: ID
Illinois: IL
Indiana: IN
Iowa: IA
Kansas: KS
Kentucky: KY
Louisiana: LA
Maine: ME
Maryland: MD
Massachusetts: MA
Michigan: MI
Minnesota: MN
Mississippi: MS
Missouri: MO
Montana: MT
Nebraska: NE
Nevada: NV
New Hampshire: NH
New Jersey: NJ
New Mexico: NM
New York: NY
North Carolina: NC
North Dakota: ND
Ohio: OH
Oklahoma: OK
Oregon: OR
Pennsylvania: PA
Rhode Island: RI
South Carolina: SC
South Dakota: SD
Tennessee: TN
Texas: TX
Utah: UT
Vermont: VT
Virginia: VA
Washington: WA
West Virginia: WV
Wisconsin: WI
Wyoming: WY
Zip
Highest Grade Completed
Occupation
Place of Employment
Home Phone
Work Phone
Cell Phone
Email Address
Religious Affiliation
FATHER'S INFORMATION
Name
Date of Birth
SSN
Address
City
State
Alabama: AL
Alaska: AK
Arizona: AZ
Arkansas: AR
California: CA
Colorado: CO
Connecticut: CT
Delaware: DE
Florida: FL
Georgia: GA
Hawaii: HI
Idaho: ID
Illinois: IL
Indiana: IN
Iowa: IA
Kansas: KS
Kentucky: KY
Louisiana: LA
Maine: ME
Maryland: MD
Massachusetts: MA
Michigan: MI
Minnesota: MN
Mississippi: MS
Missouri: MO
Montana: MT
Nebraska: NE
Nevada: NV
New Hampshire: NH
New Jersey: NJ
New Mexico: NM
New York: NY
North Carolina: NC
North Dakota: ND
Ohio: OH
Oklahoma: OK
Oregon: OR
Pennsylvania: PA
Rhode Island: RI
South Carolina: SC
South Dakota: SD
Tennessee: TN
Texas: TX
Utah: UT
Vermont: VT
Virginia: VA
Washington: WA
West Virginia: WV
Wisconsin: WI
Wyoming: WY
Zip
Highest Grade Completed
Occupation
Place of Employment
Home Phone
Work Phone
Cell Phone
Email Address
Religious Affiliation
STEP-PARENT / GUARDIAN INFORMATION
Name
Date of Birth
SSN
Address
City
State
Alabama: AL
Alaska: AK
Arizona: AZ
Arkansas: AR
California: CA
Colorado: CO
Connecticut: CT
Delaware: DE
Florida: FL
Georgia: GA
Hawaii: HI
Idaho: ID
Illinois: IL
Indiana: IN
Iowa: IA
Kansas: KS
Kentucky: KY
Louisiana: LA
Maine: ME
Maryland: MD
Massachusetts: MA
Michigan: MI
Minnesota: MN
Mississippi: MS
Missouri: MO
Montana: MT
Nebraska: NE
Nevada: NV
New Hampshire: NH
New Jersey: NJ
New Mexico: NM
New York: NY
North Carolina: NC
North Dakota: ND
Ohio: OH
Oklahoma: OK
Oregon: OR
Pennsylvania: PA
Rhode Island: RI
South Carolina: SC
South Dakota: SD
Tennessee: TN
Texas: TX
Utah: UT
Vermont: VT
Virginia: VA
Washington: WA
West Virginia: WV
Wisconsin: WI
Wyoming: WY
Zip
Highest Grade Completed
Occupation
Place of Employment
Home Phone
Work Phone
Cell Phone
Email Address
Religious Affiliation
GENERAL INFORMATION
Please describe the presenting problem
List your child’s interests/hobbies/skills
What languages are spoken in home?
How many homes has the child lived in?
With whom does the child share a bedroom and/or bed?
Who cares for the child during the day?
In what year were the natural parents married?
How many years were parents married before the birth or adoption of 1st child?
In what year were the parents separated, if applicable?
Divorced?
Who has legal custody of the child?
Are you authorized to seek counseling for this child?
Yes
No
In what year was the custodial parent remarried, if applicable?
This child is
Natural
Adopted
List any known problems encountered during this pregnancy
What was child’s birth weight?
Were eating habits
Regular
Irregular
Were sleeping habits
Regular
Irregular
If irregular, please explain
What was child’s approach to new situations
Positive
Withdrawn
Slow to warm-up
What was child’s reaction to new stimuli?
Intense
Moderate
Little or None
When trying new things or encountering new situations, regardless of your child’s initial reaction, would you describe your child as
Adaptable
Slow to Adapt
Unadaptable
Your child’s activity level would be described as
Extreme
Moderate
Quite
At what age was toilet training started?
At what age was it established?
Describe any struggles, if any, with toilet training
Does your child ever wet the bed?
Yes
No
If so, how often?
Does your child ever soil or have toileting accidents?Does your child ever soil or have toileting accidents?
Yes
No
If so, where is the child when soiling or wetting occurs
Does it occur
Night
Both
How is discipline handled in the home?
Describe any traumatic events that your child has been through (deaths, abuse, moves, etc.)
PAST CONSULTATION
Have you contacted counselor/psychologist/psychiatrist in the past?
Yes
No
If so, what was the outcome?
Is your child on medication?
Yes
No
If yes, please list medications and dosage
Is your child attending school?
Yes
No
Is your child expected to
Pass
Fail this year
What special services, if any, is your child receiving in school?
In what subjects and for how many hours per day?
Has your child ever failed a class or been held back?
Yes
No
If yes, please describe
Is your child presently receiving counseling in the school?
Yes
No
If yes, from whom?
Phone number
May we contact him/her?
Yes
No
Please list any additional information which you feel we should know about
REFERRAL INFORMATION
How did you find us (referred by doctor, friend, family, church, other)
INSURANCE INFORMATION
Insurance Company
Policy/Group #
Address
City
State
Alabama: AL
Alaska: AK
Arizona: AZ
Arkansas: AR
California: CA
Colorado: CO
Connecticut: CT
Delaware: DE
Florida: FL
Georgia: GA
Hawaii: HI
Idaho: ID
Illinois: IL
Indiana: IN
Iowa: IA
Kansas: KS
Kentucky: KY
Louisiana: LA
Maine: ME
Maryland: MD
Massachusetts: MA
Michigan: MI
Minnesota: MN
Mississippi: MS
Missouri: MO
Montana: MT
Nebraska: NE
Nevada: NV
New Hampshire: NH
New Jersey: NJ
New Mexico: NM
New York: NY
North Carolina: NC
North Dakota: ND
Ohio: OH
Oklahoma: OK
Oregon: OR
Pennsylvania: PA
Rhode Island: RI
South Carolina: SC
South Dakota: SD
Tennessee: TN
Texas: TX
Utah: UT
Vermont: VT
Virginia: VA
Washington: WA
West Virginia: WV
Wisconsin: WI
Wyoming: WY
Zip
Phone number
Insurance Type
HMO
PPO
Has deductible been met?
Yes
No
Does your insurance company require prior authorization?
Yes
No
If so, please provide the authorization number #
Parent / Guarding Digital Signature
SUBMIT
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