Minor Client Intake Form
Minor's Name
*
First Name
Last Name
Parent's Name(s)
*
First Name
Last Name
First Name
Last Name
Minor's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Minor's Date of Birth
*
-
Month
-
Day
Year
Date
Age of Minor
Parent's Email(s)
example@example.com
example@example.com
Parent Phone Number(s)
*
-
Area Code
Phone Number
-
Area Code
Phone Number
Emergency Contact (Other than parents)
Name
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Relationship
*
General Information
Child lives with:
both biological parents
mother
father
mother & stepfather
father & stepmother
other
Use this space to give any further information on living arrangements or custody agreements.
List all people living in the minor's household. (Names and Ages) Please also mention whether the relationships are positive or not.
Does your child have any physical problems that require medication or physical care?
Yes
No
If yes, please describe the physical problems.
Medical History
List child's past or present illness, operations, and injuries. Indicate age when occurred and describe how severe. Please pay special attention to head injuries and any time when your child was unconscious, had convulsions, high fever, or was delirious.
How is the child's vision?
How is the child's hearing?
When did your child last have a physical examination? Please give physician's name and phone number.
If your child is currently receiving medical treatment, list physicians and treatments.
If your child is using any medications, please list all medication(s) currently using.
Seeing Anyone Else?
Is your child CURRENTLY seeing a counselor, psychologist, psychiatrist or other mental health professional?
*
Yes
No
Professional's Name
First Name
Last Name
Professional's Phone Number
Has the child PREVIOUSLY seen a counselor, psychologist, psychiatrist or other mental health professional?
*
Yes
No
Please list professional(s) names, locations, and phone numbers (if you have them).
Educational Information
Current School Name
Grade Level
Has child ever repeated a grade?
Yes
No
If yes, which grade?
How does your child get along at school?
Any difficulties learning at school?
Yes
No
If yes, please explain.
Problem Areas
Problem Areas: In the following list mark any area of your child's life that are of concern to you.
Anger/Temper
Depression
Family Problems
Education
Fearfulness
Physical Problems
Marital Problems
Problems with Social Relationships
Problems with Children
Religious / Spiritual Concerns
Thoughts of Harming Myself or Others
Trouble Making Decisions
Unhappy Most of the Time
Use of Alcohol or Drugs
Worry
Work
Stress
Sexual Issues
Other (specify below)
Please list specific or detailed explanation for any items you checked.
Which of those you checked are the most important concerns to you right now?
Describe any emotional or spiritual problems your child is having. If possible, list questions you want answered.
Has your child ever suffered abuse? (check all that apply)
Physical abuse
Emotional abuse
Sexual abuse
Spiritual abuse
Not suffered abuse that I know of
You may use this space to briefly explain any abuse your child has suffered, if you feel it is relevant.
Spiritual History
This is Christian counseling. Do you believe your child is a Christian?
Yes
No
I'm not sure
Does your child go to a particular church?
Yes
No
If yes, which one?
Is he/she active at this church?
Yes
No
Not applicable
Final Questions
Who suggested that you see a counselor?
No-one (self-referral)
Friend
Family member
Co-worker
Spouse or Partner
Other (specify below)
Other
If a former client of ours recommended counseling, please tell us who.
Briefly describe your reasons for seeking Christian counseling at this time.
What do you expect your child to gain from this counseling? How would things be different if the difficulties were resolved?
Is there anything else you believe might be important for your counselor to know at this time?
I learned about your services from:
Additional comments or concerns
*Your signature below indicates that the information you have provided above is truthful.
Date
-
Month
-
Day
Year
Date
Signature
*
Submit
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