Parent Child Therapeutic Services Intake Form

Parent Child Therapeutic Services
Caregiver Information:
Parent/Guardian Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Age:
Geographical Location & Housing Type:

N PortlandNW PortlandSE PortlandSW PortlandDV ShelterHouselessDoubled Up TemporaryDoubled Up PermanentRent House/ApartmentOwn House/CondoOther ShelterTransitional HousingOther:NE Portland
Marital Status

SingleMarried/PartneredSeparatedDivorced
Parent/Guardian Ethnicity:

Latino/LatinaWhiteSlavicAfrican-AmericanPacific IslanderAfrican ImmigrantAmerican IndianAsian ImmigrantAsian
Primary Language Spoken in the home

English
Custody Type:

Biological MotherBiological FatherGrandparent
Parent/Guardian Gender

FemaleMaleNon binaryNot given
Source(s) of Household Income

Child SupportEmploymentUnemployedTANFSSIFood stamps
Average Monthly Household Income:
Other Economic Information?
Parent/Guardian Military Status
Parent-Child Counselor Name (If Known):
Referred by: (Include Name & Contact Information If known)
Who referred you to our services?
Date of Referral:

MonthDayYear
Date
Involved with CPS?:

Yes NoIn the Assessment Phase?Voluntary CPS Case?
Transportation Available?

NoYes
Today's Date:

MonthDayYear
Date
Primary Client Information

Person to Receive Services
*Primary Client Name (and/or Child to Receive Services)

First NameLast Name
Gender
Age
Race/Ethnicity

LatinoBlack/AfricanNative AmericanAsian/Pacific IslanderWhiteEastern European
Date of Birth

MonthDayYear
Date

Siblings or other Family Members

	First & Last Name	Age	Gender	Ethnicity/Race	Ethnicity/Race	Date of Birth	Lives with Caregiver?
Sibling or Family Member
Sibling or Family Member
Sibling or Family Member
Sibling or Family Member

Describe the Main Reason you are seeking services now:
How will you know services were successful after they have ended?
What would you like to accomplish?
Please check all that apply (for the Primary Client):

Anger or hostile feelingsAnxiety, nervousness, fearsSadness or DepressionFamily issuesProcrastinationEmotional distressFamily & Relationships concernsShynessTraumatic experiencesSocial conflictsSuicidal feelings or behaviorsStressSleep disorderSelf-controlSelf-esteem or confidenceWork or career concernsParenting issuesGrief

Family History
Include Strengths, Challenges, Siblings or Other significant information to consider
Cultural Considerations you would like to included
Include Language, Spiritual, or Other Considerations
Accommodations Needed?
Sight, Hearing, Physical, or Other Needs
School/Preschool
Include IEP, Discipline, or Other Important Information
List any *Past or *Current Counseling or Mental Health Services Received
School Counseling, Psychologist, or Others
Strengths (Include Clients Interests, Hobbies, or Other Information)
Strengths
Were there any Health Challenges Before or During Birth?
Any past hospitalizations or health concerns?

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Parent Child Therapeutic Services

Caregiver Information:

Primary Client Information