Child Intake Form

Child Intake Form
Child's Full Name*

First NameMiddle NameLast Name
Nick Name / Preferred Name
If Applicable
Administrative Sex:
Gender Identity:
Sexual Orientation
Today's Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent / Guardian Name*

First NameLast Name
Address (if different from address above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Insurance Information
Insurance Name:*
Insurance ID:*
Group #*
Behavioral Observations:
What does your child currently do too often, too much, or at the wrong times that gets him/her in trouble? Please list all behaviors you can think of:
What does your child fail to do as often as you would like, as much as you would like, or when you would like? Please list all the behaviors you can think of:
What does your child do that you like? What does he/she do that other people like? Please list all the behaviors you can think of:
Do you have any other concerns about your child or your family that you have not mentioned yet?
Treatment Goals:
From your preceding list of your child's behavior and your family concerns, what problem behaviors do you want to see change FIRST: and how much must they change for you to be satisfied?
Family History:
Biological Mother's Name

First NameLast Name
Biological Father's Name:

First NameLast Name
Who has legal guardianship of your child?
Is there currently a custody agreement in place?

YesNo
Upload Custody agreement

Browse Files
Custody or court decrees Cancelof

Who lives in your household?

Rows	Name	Age	Relationship
1
2
3
4
5
6

Who are significant person NOT living with your child?

Rows	Name	Age	Relationship
1
2
3
4
5
6

Please describe any past counseling that either your child or any family member has had:
Does anyone in the child's family use currently (or in the past) any type of of drug, tobacco, or alcohol?

YesNo
If yes, please describe:
Religious Preference
Educational History:
What school does your child attend?
Current Grade:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Teacher's Name:
Please list other schools your child has attended (including preschool):
What does your child's teacher say about him/her?
Has your child ever repeated a grade? If so which one(s):
Has your child ever received special education services? If so please describe:
Has your child experienced any of the following problems at school?

FightingLack of friendsDrug/AlcoholDetentionSuspensionLearning DisabilitiesPoor attendancePoor gradesGang influenceIncomplete homeworkBehavioral problems
Medical Care:
Name of Primary Care Physician:
Name of Clinic:
Address of Clinic:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you selected 'Yes' please fill out a Release of Information for your medial provider using this link, or ask for one at your first appointment.

*********
Date of your child's last medical examination:

MonthDayYear
Date
May I contact your child's medical doctor so that they can be fully informed and we can coordinate his/her care?

YesNo
Has your child's experienced any of the following medical problems? Check all that apply:

A serious accidentHospitalizationSurgeryAsthmaA head injuryHigh feverConvulsions/seizuresEye/ear problemsMeningitisHearing problemsAllergiesLoss of consciousness
Did the child's mother smoke tobacco or use any alcohol, drugs, or medications during pregnancy? If so, please list which ones:
Did the child's mother have any problems during the pregnancy or during delivery? Please yes, please describe:
Please list any current medical problems or physical handicaps:

Current Medications:

Rows	Name of Medication	Dosage	Who prescribes medication
1
2
3
4
5

Other History:
Has your child ever experienced any type of abuse(physical, sexual, or verbal)> If so, please describe:
Has your child ever made statements of wanting to hurt him/her self or seriously hurt someone else? Has he/she every purposely hurt him/her self or another? If yes to either, please describe the situation:
Has your child ever experiences any serious emotional losses(such as death of or physical separation from a parent or other caretaker)? If yes, please explain:
Finally, what are some of the things that are currently stressful to your child and his/her family?
Should be Empty:

Child Intake Form

Insurance Information