Children's Center - Child Intake / History Form

CHILD INTAKE/HISTORY FORM
Child's Name
Date

Month Day Year
Date
Age
Birthdate

Month Day Year
Date
Grade
School
Home Street Address
City
State
Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Email
example@example.com
PARENTS / PRIMARY CARETAKERS
Mother's Name

First Name Last Name
Age/DOB
Father's Name

First Name Last Name
Age/DOB
Does your child have other parents(s) / Stepparent(s)?
Name/Age of siblings
Who lives in the household with the child currently?
Are there any significant family or marital conflicts?
PRESENTING PROBLEM
What are the concerns or difficulties that cause you to seek professional help at this time?
DEVELOPMENTAL HISTORY
Infancy / Early Development
Did the child have colic or significant irritability?

Yes No
Was there any feeding difficulties? Sleeping difficulties?
Was the child normally active?
Was the baby able to gain weight and grow normally?
Was early development significantly different from the child's sibling? (if applicable)
Early Developmental Milestone History
Were language, motor, and social milestones achieved within normal limits?
Past Therapeutic Services (i.e. Speech, Occupational, Behavioral)
MEDICAL HISTORY
What is your child's present health?

Excellent Good Fair Poor
Has the child had any serious illnesses, injuries or other health problems?
Is the child currently taking any medications?
Does the child have a special diet or is he/she taking dietary supplements?
Are there any specialty physicians involved in the child's care?
BEHAVIORAL/EMOTIONAL CONCERNS:
Does your child exhibit any of the following behaviors? Are any of the behaviors of particular concern?

Short Attention Cruelty to Animals Food Refusal Sensory Distractible Interests Fire Setting Pica Restricted Hyperactive Behaviors Oppositional/Defiant Self-Injury Repetitive Impulsive Lying Head Banging Poor Eye Contact Aggressive Truant Peculiar Habits Literal Destructive Sexualized Behaviors Toe Walking Attention Seeking Masturbates Nail Biting Fearless Peer Problems Mood Swings Hallucinations Social Anxiety Mood Lability Stranger Anxiety Suicidal Thoughts/Attempts Separation Anxiety Anorexia Excessive Crying Binging/Purging Excessive Laughing
Comments
Has your child ever experienced any traumatic events (e.g., death of a close relative or friend, accident, etc.)? If yes, please describe
Is there a history of physical or sexual abuse, family violence or neglect?

Yes No
If yes, please explain
Has your child ever had counseling, psychotherapy and/or psychological testing?

Yes No
If yes, date(s)
Agency or name of doctor/ therapist(s)
Has your child ever seen a psychiatrist or received medication for behavior, attention or emotional problems?

Yes No
If yes, date(s)
Name of prescribing doctor and medication
Type of Discipline used in the home?
Who is the primary disciplinarian?
Is discipline generally effective?
EDUCATIONAL HISTORY
Does the child have an Individualized Educational Plan (IEP)?
Has the child ever repeated or skipped any grades?
Have the teachers reported problems in any of the following areas?

Reading Attention/Concentration Spelling Hyperactivity Math Behavior Writing Social Adjustment
If so, please explain
Please describe how your child gets along with other students at school:
How does the child get along with teachers?
History of suspensions/detentions/behavior difficulties?
SOCIAL HISTORY
How does the child get along with peers?
Does the child get along with adults?
Does the child understand social cues? (ex. When someone is angry)
Is the child shy?
Around familiar individuals?
Does the child prefer to be/play with others or alone?
What are the child's extracurricular activities?
What activities does the child enjoy?
Has the child's social skills or relationships changed recently?
Does the child become overly anxious or upset when separated from parents?
FAMILY HISTORY
Has anyone in the immediate or extended family (of either parent) had any of the following problems?

Late Walking Late Talking Learning Problems Mental Retardation / Intellectual Disability Special Education Speech Therapy / Speech Difficulties Autism Spectrum Disorder ADHD Cerebral Palsy Depression Bipolar Disorder / Manic Depression Schizophrenia Mental Illness (other than those listed) Other
Which family members can be involved in this child's case?
Describe your relationship with your child. What do you do together regularly?
Should be Empty:

CHILD INTAKE/HISTORY FORM

PARENTS / PRIMARY CARETAKERS

PRESENTING PROBLEM

DEVELOPMENTAL HISTORY

MEDICAL HISTORY

BEHAVIORAL/EMOTIONAL CONCERNS:

EDUCATIONAL HISTORY

SOCIAL HISTORY

FAMILY HISTORY