2a. Intake Form (Child & Adolescent)

Client # (office staff):
Agape Psychological Consortium

Intake Form (Child & Adolescent)
Identifying Information:
Current Date:

MonthDayYear
Client's Name*

First NameLast Name
Date of Birth:*

MonthDayYear
Current Age:
Race:*
Primary language spoken in home:
MaleFemale
Reason(s) for seeking services at this time:
TherapyEvaluationConsultation
YesNo
If yes, when:
Parent/Legal Guardian Information:
Name:*

First NameLast Name
Relationship to child:*
YesNo
Primary Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone #:*
Secondary Phone #:
Client/Legal Guardian Email:*
Family Information:
Family members/other significant relationships in child's life:
Out of Home Placement Information:
Program name:
Admission Date:
Director/Administrator's Name#:
Primary Phone #:
Educational/Work History:
Name of current school:*
Grade level on this date:*
YesNo
YesNo
YesNo
YesNo
YesNo
If yes, where & how long?
Psychiatric History:
YesNo
If yes, where/with whom:
YesNo
If yes, who:
YesNo
If yes, what:
YesNo
EmotionalPhysicalSexual
YesNo
If yes, why:
YesNo
If yes, what:
YesNo
If yes, what:
YesNo
If yes, what:
List any prescribed medications:
Legal Issues:
YesNo
Current status:
If legal problems, charges:
YesNo
Charges:
Special Considerations:
YesNo
YesNo
Alcohol/Substance Use History:
YesNo
YesNo
YesNo
If yes, what?
Lethality History:
YesNo
YesNo
YesNo
YesNo
Treatment Plan:
What things have you done so far to help your child with the current situation?
a.
b.
What goals would you want to work on in treatment for your child?
a.
b.
Referral Information:
Name of referring person/doctor:
Name of referring program/office:
YesNo
Phone #:
Fax #:
Primary Care Physician:
Primary Care Physician:
Name of Practice:
Address location:
Phone #:
Fax #:
Emergency Contact:
Person to call in case of an emergency:
Phone #:
Authorization:
As legal guardian of this particular minor client, I have the legal authorization to give Agape Psychological Consortium permission to:
YesNo
YesNo
My typed initials acknowledges that I have read this Client Intake form:*
Date signed:

MonthDayYear
My typed initials acknowledges that I am the client/legal guardian listed on this document:*
Date signed:

MonthDayYear
Should be Empty:

Agape Psychological Consortium