Family Intake
Caregiver 1 Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Gender
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Occupation
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Caregiver 2 Name
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First Name
Last Name
Date of Birth
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Month
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Day
Year
Date
Gender
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Occupation
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Please list all children (include name, age and gender)
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Presenting Problem
What is the main concern that brings you to therapy?
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How long has this been a concern?
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What have you already tried to address the problem? Has anything been helpful so far?
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What do you hope to get from therapy?
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Psychiatric and Medical History
Is there any history of trauma or upsetting life events (such as abuse, life threatening accidents or medical concerns, family conflict, bullying, etc)?
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yes
no
If yes to above question, please describe
Have any family members received psychotherapy or counseling before?
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yes
no
If yes to above question, please describe
Have any family members been given a previous psychological diagnosis?
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yes
no
If yes to above question, please describe
Is any family member currently taking any medication for emotional or behavioral reasons?
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yes
no
If yes to above question, please list name of mediation, dosage and reasons prescribed.
Has any family member ever been hospitalized for emotional or behavioral concerns?
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yes
no
If yes to above question, please describe reason and name of hospital.
Is there any use of drugs or alcohol by family members?
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yes
no
If yes to above question, please describe
Please describe any current medical concerns for family members
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is there any history of DCFS/CPS involvement?
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yes
no
If yes to above question, please describe.
Developmental, Social and Educational History of Children
During pregnancy, was there any use of drugs/alcohol, exposure to domestic violence, major illnesses/accidents, or significant stressors?
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yes
no
If yes to above question, please describe
Was there any delays in reaching early developmental milestones such as walking, speech or toilet trainings?
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yes
no
If yes to above question, please describe
Do you have any concerns regarding your child(ren's) social relationships?
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yes
no
If yes to above questions, please describe
Do you have any concerns regarding educational issues for your child(ren)?
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yes
no
If yes to above question, please describe
Family Information
Other immediate family members that live outside of the home (ie parents or siblings)?
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Are there extended family members or others that you consider part of your family's support system?
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Does your family actively participate in religion/spirituality?
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yes
no
Does your family consider religion/spirituality to be a source of support?
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yes
no
Please describe your parenting and discipline style. How do you address discipline concerns with your children?
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What do you consider to be your family strengths?
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What do you feel that you need to improve or change as a family?
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Please share any past or current stressors or major life changes that have impacted your family?
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Is there any other information you want to share regarding your family?
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E-Signature: I consent to sharing of information provided here
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Today's Date
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Month
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Day
Year
Date
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