Parent Child Therapeutic Services Intake Form

Parent Child Therapeutic Services
Caregiver Information:
Parent/Guardian Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Date of Birth:

Month Day Year
Date
Age:
Geographical Location & Housing Type:

N Portland NW Portland SE Portland SW Portland DV Shelter Houseless Doubled Up Temporary Doubled Up Permanent Rent House/Apartment Own House/Condo Other Shelter Transitional Housing Other: NE Portland
Marital Status

Single Married/Partnered Separated Divorced
Parent/Guardian Ethnicity:

Latino/Latina Caucasian Slavic African-American Pacific Islander African Immigrant American Indian Asian Immigrant Asian
Primary Language Spoken in the home

English
Custody Type:

Biological Mother Biological Father Grandparent
Parent/Guardian Gender

Female Male Non binary Not given
Source(s) of Household Income

Child Support Employment Unemployed TANF SSI Food stamps
Average Monthly Household Income:
Other Economic Information?
Parent-Child Counselor Name (If Known):
Referred by: (Include Name & Contact Information If known)
Who referred you to our services?
Date of Referral:

Month Day Year
Date
Involved with CPS?:

Yes No In the Assessment Phase? Voluntary CPS Case?
Transportation Available?

No Yes
Today's Date:

Month Day Year
Date
Primary Client Information

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

First Name Last Name
Gender
Age
Race/Ethnicity

Latino Black/African Native American Asian/Pacific Islander White Eastern European
Date of Birth

Month Day Year
Date

Siblings or other Family Members

First & Last Name

Age

Gender

Ethnicity/Race

Date of Birth

Lives with Caregiver?

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 feelings Anxiety, nervousness, fears Sadness or Depression Family issues Procrastination Emotional distress Family & Relationships concerns Shyness Traumatic experiences Social conflicts Suicidal feelings or behaviors Stress Sleep disorder Self-control Self-esteem or confidence Work or career concerns Parenting issues Grief

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?

Upload Any Additional Forms Here (*Optional)

Browse Files

Cancel of
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Parent Child Therapeutic Services

Caregiver Information:

Primary Client Information