CHILD INTAKE/HISTORY FORM
Home Street Address
Home Phone Number
Cell Phone Number
PARENTS / PRIMARY CARETAKERS
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?
What are the concerns or difficulties that cause you to seek professional help at this time?
Infancy / Early Development
Did the child have colic or significant irritability?
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)
What is your child's present health?
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?
Does your child exhibit any of the following behaviors? Are any of the behaviors of particular concern?
Cruelty to Animals
Poor Eye Contact
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?
If yes, please explain
Has your child ever had counseling, psychotherapy and/or psychological testing?
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?
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?
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?
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?
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?
Has anyone in the immediate or extended family (of either parent) had any of the following problems?
Mental Retardation / Intellectual Disability
Speech Therapy / Speech Difficulties
Autism Spectrum Disorder
Bipolar Disorder / Manic Depression
Mental Illness (other than those listed)
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: