Family Intake Form
Parent Name
*
DOB
*
Address
*
Cell Phone
*
Format: (000) 000-0000.
Alternate Phone
Format: (000) 000-0000.
Email Address
*
example@example.com
Birthplace
Education (highest level)
Occupation
Parent Name
DOB
Address
Cell Phone
Format: (000) 000-0000.
Alternate Phone
Format: (000) 000-0000.
Email Address
example@example.com
Birthplace
Education (highest level)
Occupation
Parent's relationship status
*
Married
Separated/Divorced
Never Married
Child's Name
*
First Name
Last Name
DOB
*
Grade
Child's Name
First Name
Last Name
DOB
Grade
Child's Name
First Name
Last Name
DOB
Grade
Child's Name
First Name
Last Name
DOB
Grade
If parents are not together, what is the current custody and time sharing arrangement
Please list other family members living in the home or that are significant in your child's life:
Name
First Name
Last Name
Age
Gender
Female
Male
N/A
Relationship
Lives With
Yes
No
Name
First Name
Last Name
Age
Gender
Female
Male
N/A
Relationship
Lives With
Yes
No
Name
First Name
Last Name
Age
Gender
Female
Male
N/A
Relationship
Lives With
Yes
No
Name
First Name
Last Name
Age
Gender
Female
Male
N/A
Relationship
Lives With
Yes
No
Are there cultural or religious beliefs that are important to the family?
*
Yes
No
If yes, please explain
Please circle any past, present, or impending problems/stressors in the family:
*
Physical / Sexual Abuse
Isolation
Deaths
Divorce
Legal Issues
Financial / Unemployment
Health Concerns
Emotional / Behavioral Concerns
Frequent Relocations
Eating Disorders
Alcohol / Drug Addictions
Suicide Attempts / Ideation
Learning Disabilities
High Conflict Relationships
If yes, please describe and for whom?
Family Medical History
Please list any medical problems or physical handicaps of family members (e.g. headaches, dyslexia, diabetes, etc.)
Family / Personal Physician
Please list any medications individual members are taking and what they are for:
Is anyone in the family using (or in the past) any type of drugs tobacco or alcohol?
*
Yes
No
Please describe:
Please list any previous therapy:
Has anyone in the family ever been hospitalized for psychiatric reasons?
*
Yes
No
If yes, please describe:
Has anyone in your family experienced any significant stressors or traumatic event?
*
Yes
No
If yes, when?
Please describe:
Submit
Should be Empty: