• ALCS Adolescent Intake Form (Parent/Guardian)

    Thank you for choosing Abundant Life Counseling Services, P.A. So that we can better assist your teen, please fill out this form as fully and openly as possible. All information is held in strictest confidence within legal limits. If certain questions do not apply, you can leave them blank.

  • Identifying Information

  • Date of birth*
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    2 digit month, 2 digit day, 4 digit year
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  • May we call you at the phone number(s) provided above? Check all that apply.
  • May we leave you a voicemail at the phone number(s) provided above? Check all that apply.
  • May we email you at this email address?*
  • Does the adolescent attend church regularly?

  • Personal Concerns

  • Behaviors of Concern

  • Please check how often the following behaviors occur:
    Rows
  • Please check how often the following behaviors occur:
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  • Please check how often the following behaviors occur:
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  • Please check how often the following behaviors occur:
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  • Please check how often the following behaviors occur:
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  • Has the adolescent had any previous professional assistance with the problems stated here?*

  • Family History

  • Is your child adopted?
  • Are they aware of the adoption?
  • Has the teen ever been in foster care?
  • Please list all family members currently living at home or closely connected with the family. Indicate their ages, relationship to this minor and their school grade or occupation.
    Rows

  • Social Development and Peer Relationships

  • When your teen chooses friends, are they... (pick all that apply)

  • Does the adolescent prefer the company of adults to other teens?
  • Does the adolescent have at least one best friend?
  • Does the adolescent currently date?
  • Does the adolescent currently have a boyfriend or girlfriend?

  • Emotional Development

  • Please check any and all that family members, teachers or others have used to characterize your adolescent:

  • Has your adolescent experienced any type of trauma? Please check all that apply.

  • School History

  • Has this adolescent...
  • Has your teen had any remedial help or special education services in school or privately?
  • Is your adolescent currently employed?
  • Are they free to quit the job if they choose?

  • Health Information

  • Was your teen full-term?
  • Did your teen meet all their developmental milestones appropriately?
  • Do they experience food cravings?
  • Has your teen gained or lost weight in the past three months?
  • How would you rate your teen's diet?
  • Are they currently taking medications?
  • If so, please complete the following.
    Rows
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  • Date of last physical exam
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    2 digit month, 2 digit day, 4 digit year
  • Date of last routine check-up
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    2 digit month, 2 digit day, 4 digit year
  • Is your teen currently using any drugs or alcohol for recreational purposes?
  • Please list drug and/or alcohol use.
    Rows
  • Has your teen ever been arrested?
  • Have they ever been the victim of a crime?

  • For Adolescent Girls

  • Emergency Contact

    Whom should we contact in case of emergency?
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  • Should be Empty: