Intake form- Child/Adolescent

 

www.acaciachristiancounseling.com

 

Child/family history:

 

Form completed by:  { } Parent          { } Foster Parent              { } Guardian { } Other :_______________

 

Are you a single parent? { } Yes        { } No               

Child’s Name: _____________________________            DOB: _____________             Age: _______

Gender: { } Male         { } Female         Grade: _______   Name of School: ________________________

Referred by: { } Parent/Guardian       { } Pediatrician  { } School  { } EAP  { } ACCESS  { } CPS

{ } Social Services        { } Court Order  { } Other: ________________________________

Address: ________________________________ City: __________________ Zip Code: _________

Telephone: H ____________________           W ____________________ Cell ___________________

Parent’s Email Address: _____________________________________________________________

 

Therapist may leave message at : { } Home  { } Work  { } Cell  { } Email (Preferred:_______________)

 

Race/Ethnicity: _____________________________________________________________________

 

Emergency contact person: ___________________________________________________________ 

 

Relationship: _______________________________            Phone #: ___________________________

 

********************************************************************************************************************

Print name: __________________________________ Relationship to child: __________________

Child’s main problem/major reason for seeking help at this time: ______________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

How long has your child had these problems, symptoms, or issues?___________________________

_________________________________________________________________________________

_________________________________________________________________________________

Has your child had treatment for these issues in the past? { } Yes  { } No

If Yes, was the outcome helpful? { } Yes  { } No

Has your child had inpatient mental health treatment? { } Yes  { } No

Briefly describe treatment including dates, name of facility/therapist, presenting issues and outcome:

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Describe any other behavioral or emotional problems your child is having: ______________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Describe the impact of your child’s problems on the family: __________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Describe your child’s strengths and unique qualities: _______________________________________

_________________________________________________________________________________

_________________________________________________________________________________ Is your child currently under the care of a physician or psychiatrist? { } Yes   { } No

If yes: Doctor’s Name: ___________________________ Phone # ___________________________

Treatment for: _____________________________________________________________________

Is your child currently taking any medications? { } Yes  { } No  If yes, include the following information:

Name of medications Dosage Prescribed by
______________________________ ________________ _______________________
______________________________ ________________ _______________________
______________________________ ________________ _______________________

Does this child have a history of abuse (physical, sexual, emotional, neglect)? { } Yes  { } No

If yes, please describe briefly, including dates, location, perpetrators, type of abuse and impact on child/family:________________________________________________________________________ _________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Is there legal action pending related to accusations of abuse? { } Yes  { } No

If yes, describe briefly: _______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________ _________________________________________________________________________________

Is there any other legal action that may have impacted your child? Please check all that apply:

Current Past Current Past
Custody Visitation
Adoption Child Protective Services
Probation Other

 

If yes, describe briefly: _______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________ BEHAVIOR CHECKLIST   Please check any of the following behaviors that concern you:

Behavior: Current Past Behavior: Current Past
Crying, sadness, depression Temper outbursts
Loss of enjoyment of usual activities Irritability, anger
Expressing a wish to die Argues a lot
Bedtime fears, won’t sleep Disobedience
Has threatened/attempted suicide Does things that annoy others
Worries more than others Unusual fears or phobias
Panics Anxious, nervous
Repeats unnecessary act over and over Is overly concerned about things
Has rituals, habits, superstitions Twitches or unusual movements
Eats very little/fasts to lose weight Gorges or binge eats
Sleepwalking Blames others for own mistakes
Withdrawn Easily annoyed by others
Nightmares, night terrors Swears or uses obscene language
Low self-esteem Wanting to run away
Wakes up very early, unable to go back to sleep Sneaks out at night
Tiredness, fatigue Injures self
Restless sleep, wakes frequently Stealing
Trouble going to sleep Lying
Sleeps too much Hurts animals
Poor appetite Destroys property
Under or overweight Hurts people
Over-activity Drug use
Frequently acts without thinking Alcohol use
Doesn’t finish things Cigarette use
Disruptive Sexual problems
Short attention span Problems with authority
Daydreams, fantasizes Problems with the law
Easily distracted Low motivation
Hallucinations Vomits intentionally
Bedwetting/daytime wetting Soiling (pooping) in pants
Strange or unusual behavioral Disorientation

 

Forms of discipline used in the home:           { } Time out      { } Loss of privileges { } Grounding

{ } Rewards/incentives           { } Extra chores           { } Physical/corporal punishment

{ } Other: _________________________________________________________________________

 

Relationship Development  Check each item that describes your child:

Current Past Current Past
Prefers to be alone Is demanding and bossy
Is alone a lot, but dislikes this and feels lonely Fights with others
Is shy Bullies others
Has few friends Teases a lot
Has many friends Plays with younger kids
Plays with “problem kids” Plays with older kids
Is picked on a lot Poor relationships with peers
Is oversensitive Conflict with parents/step-parents
Poor relationships with teachers Has difficulty getting along with brothers and sisters

 

 

School  Check any area of concern:

Current Past Current Past
Dislikes school Missed many school days
Works hard but does not do well Repeated a grade
Unmotivated, refuses to complete work Discipline referrals, detentions
Learning problems Suspensions (how many? ___)
Expulsions (how many? _____)

 

If your child has been suspended or expelled, please explain: ________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________ School Environment  Check all that apply:

Current Past Current Past
Resource classes/special ed. Continuation school
Gifted program Home study
Speech therapy Independent study
Other programs

 

If other programs, please explain: ______________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

 

Family Stresses Check all that apply:

Current Past Current Past
Marital problems Housing problems
Marital separation Legal issues
Divorce Death of a friend
Custody disputes Death of a relative
Financial problems Death of a pet
Job loss Family illness
Parents using alcohol/drugs Other stressors:

 

If other stressors, please describe: _____________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

 

Developmental History  During pregnancy, did mother:

{ } drink             { } drugs         { } illness         { } accident

{ } problems with pregnancy              { } problems with labor           { } problems with delivery

If yes, please describe: ______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________ Please check if child is/was delayed in any of the following areas:  { } holding head up

{ } turning over  { } sitting up  { } crawling  { } walking alone  { } weaning  { } feeding self

{ } toilet training  { } using single words  { } using sentences  { } dressing self  { } sleeping through night

Briefly explain any delays: ____________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

As a baby/toddler, was child: check all that apply

{ } eating well  { } colicky  { }head banging  { } performing rocking behavior  { } clumsy

{ } easy to regulate (sleeping/eating)  { } wanting to be left alone  { }adaptable to transitions   { } more interested in things than people  { } easy to soothe  { } performing daredevil behavior Medical History  Indicate if your child has had any of the following:

Condition Yes No Age Details
Serious Infection
Convulsions/seizures
Head injuries
Other injuries
Hospitalizations
Surgeries
Ear infections
Poisonings
Allergies
Asthma
Alcoholism
Drug Use
Sexual Problems

 

Does your child have any other medical conditions? { } Yes  { } No

If yes, please describe: ______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________ Does your child frequently complain of bodily aches and pains?  { } Yes  { } No

If yes, please describe: ______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

 

Does your child miss school because of his/her physical complaints?  { } Yes  { } No

If yes, please describe: ______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

 

Does your child have any allergies to medications, drugs or foods?  {  } Yes  { } No

If yes, please describe: ______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

 

Family Information: List all of the people who currently live with the child

Name Age Relationship Occupation/School and Grade

 

Indicate if any family members or relatives have the following:

Mother Father Brother Sister Other
Problem: Now Past Now Past Now Past Now Past Now Past
Problems with attention, activity or impulse control as a child
Learning disabilites
Did not graduate from high school
Alcohol abuse
Drug use
Problems with aggressive behavior as adult or child
Antisocial behavior (arrests, jail, legal problems, probation, other
Abuse victim
Abusive to others
Depression
Nervous disorders
Mental retardation
Serious illness or surgeries
Physical handicaps
Tics or unusual movements
Other mental problems

 

What are your family supports? (church, friends, clubs etc.) __________________________________

_________________________________________________________________________________

_________________________________________________________________________________

What are your family strengths? _______________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

Additional comments: _______________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

_________________________________________________________________________________

 

Please list any adults who are authorized to drop off or pick up your child from his/her therapy session in the event you or another legal guardian are unavailable:

Name Relationship to child

 

Please note:  An authorized adult must remain in the waiting room at all times when a minor is in a therapy session. 

 

I authorize the above named person(s) to drop off or pick up my child from his/her therapy session. I agree that I or any person named by me (listed above) will not leave the premises and will remain in the waiting room for the duration of my child’s therapy session. 

 

_________________________________________ ___________________________________
Child’s Name                                                              

 

 

 

Date of Birth
_________________________________________ ___________________________________
Print Parent/Guardian Name                                   

 

Relationship to child
_________________________________________ ___________________________________
Signature                                                                     Date

Page

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s