Child and Adolescent Intake

For Ages 4 & Up

CHILD INFORMATION

Child's Name*

Date of Birth

Address

City

State

Zip

SSN

Last grade completed in school

Grade Average

Name of School

MOTHER'S INFORMATION

Name*

Date of Birth

SSN

Address

City

State

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

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

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Withdrawn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? 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

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

Verification

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