Counseling Intake Form

Counseling Intake Form
Advanced Therapy Clinic Counseling
Child/Adolescent BioPsychoSocial Assessment

(for parent and/or child/adolescent to complete)
Patient Name
Child's Age
Patient Date of Birth

MonthDayYear
Date
Patient Gender
Parent/Guardian Name
Relation to the patient
Patient Address
Contact phone number
Contact Email
School Child Attends:
Grade
School Release Signed? (see release in packet)

YesNo
Top 3 Concerns/Reasons for Seeking Services: (Please note when these concerns first started for your child , ex: age 3 after attending a friend’s birthday party)
Who resides in the home? (Please list names/ages/relationship to the child). Any Pets? Parents/Guardians- What is your occupation?
How does everyone get along?
Here is a list of common symptoms – please feel free to check those that concern you about your child.

Depression/SadnessWithdrawnLow Self-EsteemLoss of InterestsSelf Injurious BehaviorPoor Sleep Patterns/NightmaresPoor Social SkillsDefiant/UncooperativeAnger ProblemsAggressionTowards OthersDrug/Alcohol UseOver SexualizedBehaviorsPoor Self ControlDestruction ofPropertyHyperactivityInattentive/Poor FocusExcessiveFears/WorryBedwetting orEncopresis/EnuresisHallucinations/ Delusions Or DissociationsRegressive Traits/Immature for AgePhysical SymptomsLyingChange in GradesChange in Appetite
Has your child ever had counseling before? Yes No Any psychiatric hospitalization? Yes No
If yes, please note where and the dates of service:
Any involvement in the legal system Yes No On probation? Yes No
If yes, please explain below:
Family Dynamics
Family History of Mental Health Concerns:
Family History of Drug/Alcohol Concerns:
Who typically disciplines the child?
How does that discipline typically look in your household? (Check those that apply)

Remove PrivilegesAdd ChoresYell/Scream/ShoutLectureTime OutIgnoreDiscuss Situation with ChildSpank with HandSpank with ObjectSend to Room (alone)Other
If other, please explain:
Are you consistent with your discipline?
How does your child typically respond when disciplined?
Risk Assessment
Has your child ever had thoughts of harming his/herself?

YesNo
If yes – has your child had a plan to do so?
Has your child ever attempted to harm his/herself?

YesNo
Has you child ever intentionally harmed an animal/pet?

YesNo
Did you ever have to call Crisis Intervention for you child?

YesNo
If yes to any questions above, please explain below:
History of Substance Use/Abuse
Has your child used/are using the following (check all that may apply/add other info as needed):

AlcoholOTC med abuseInhalantsCocaineCaffeineRx med abuseHeroin/opiatesSynthetic/Club drugsMarijuanaCigarettesHallucinogensOther
Received any drug/alcohol assessments or treatment?

YesNo
If yes, where?
Medical Information
Is your child currently on any medications? If yes please list below and who prescribes:
Please list any current medical issues, history of medical hospitalizations for medicalissues or any histories of head injuries:
How was the pregnancy/delivery with the child? Any complications? Time spent in the NICU? Ongoing medical issues as a result?

Type a question

	On Time	Early	Delayed	At what Age
Speaking
Walking
Potty Trained

Females- Menstruating? Yes No Age at first period?
Any ongoing issues with bathroom/bedwetting? Yes No If yes, please describe Type a label
Trauma History
Below is a list of common stressors for children. Please check if your child has experienced any of the following and feel free to elaborate:

Sexual AbusePhysical Abuse or NeglectEmotional Abuse or NeglectWitness to Domestic ViolenceSudden Loss of a Family Member (or Pet)Incarcerated Family Member or other AbandonmentFrequent Moving or HomelessnessWitness to Community ViolenceAlcohol or Drug Abuser in HouseholdSomeone who is Chronically Depressed/Mentally Ill or Suicidal Living in the Household
If yes, Comments/Other?
School History
Please note any issues experienced in the school setting (examples include: grades changing drastically, behavioral concerns at school, social difficulty, bullying, etc)
Is your child involved in any extra curricular activities either inside of school, church or outside of the school setting? (sports, music, clubs, youth groups, employed, etc).
What technology does your child have current access to? Please check those that apply:

Smart PhoneComputer with Internet AccessFacebook AccountTwitter AccountInstagram AccountSnapChat AccountVideo Game System(s)IPadOther
How is this technology monitored in your home?
Do you have password access?
How does your child primarilycommunicate with their friends?
Have there been any issues with your child being bullied or bullying others online? blanks If yes, please explainblank
Any other online issues? (communicating with strangers, etc) blanksIf yes – please describe: blank
Additional Supports
Please make note of any additional supports your child has in his/her life that they have regular access to (grandparents, other family members, best friends, coaches, youth advisors, etc)
Strengths
Please tell us some of your child’s biggest strengths. What are the best things about him/her?
What are his/her favorite things to do for fun?
Is there anything else you would like us to know about your child?

CYW Adverse Childhood Experiences Questionnaire (ACE-Q) Child

To be completed by Parent/Caregiver
Today's Date

MonthDayYear
Date
Child's Name

First NameLast Name
Child's Date of Birth

MonthDayYear
Date
Your Name

First NameLast Name
Relationship to Child
Many children experience stressful life events that can affect their health and wellbeing. The results from this questionnaire will assist your child’s doctor in assessing their health and determining guidance.

Please read the statements below. Count the number of statements that apply to your child and write the total number on the line provided.

Please DO NOT mark or indicate which specific statements apply to your child.
Section 1. At any point since your child was born...
- Your child’s parents or guardians were separated or divorced
- Your child lived with a household member who served time in jail or prison
- Your child lived with a household member who was depressed, mentally ill or attempted suicide
- Your child saw or heard household members hurt or threaten to hurt each other
- A household member swore at, insulted, humiliated, or put down your child in a way that scared your child OR a household member acted in a way that made your child afraid that s/he might be physically hurt
- Someone touched your child’s private parts or asked your child to touch their private parts in a sexual way
- More than once, your child went without food, clothing, a place to live, or had no one to protect her/him
- Someone pushed, grabbed, slapped or threw something at your child OR your child was hit so hard that your child was injured or had marks
- Your child lived with someone who had a problem with drinking or using drugs
- Your child often felt unsupported, unloved and/or unprotected
1) Of the statements in Section 1, HOW MANY apply to your child? Write the total number in the box.
Section 2. At any point since your child was born...
- Your child was in foster care
- Your child experienced harassment or bullying at school
- Your child lived with a parent or guardian who died
- Your child was separated from her/his primary caregiver through deportation or immigration
- Your child had a serious medical procedure or life threatening illness
- Your child often saw or heard violence in the neighborhood or in her/his school neighborhood
- Your child was often treated badly because of race, sexual orientation, place of birth, disability or religion
2) Of the statements in Section 2, HOW MANY apply to your child? Write the total number in the box.

	Not True or Hardly Ever True	Somewhat True or Sometimes True	Very True or Often True
When my child feels frightened, it is hard for him/her to breathe
My child gets headaches when he/she is at school
My child doesn’t like to be with people he/she doesn’t know well
My child gets scared if he/she sleeps away from home
My child worries about other people liking him/her
When my child gets frightened, he/she feels like passing out
My child is nervous
My child follows me wherever I go
People tell me that my child looks nervous
My child feels nervous with people he/she doesn’t know well
My child gets stomachaches at school
When my child gets frightened, he/she feels like he/she is going crazy
My child worries about sleeping alone
My child worries about being as good as other kids
When he/she gets frightened, he/she feels like things are not real
My child has nightmares about something bad happening to his/her parents
My child worries about going to school
When my child gets frightened, his/her heart beats fast
He/she gets shaky
My child has nightmares about something bad happening to him/her
My child worries about things working out for him/her
When my child gets frightened, he/she sweats a lot
My child is a worrier
My child gets really frightened for no reason at all
My child is afraid to be alone in the house
It is hard for my child to talk with people he/she doesn’t know well
When my child gets frightened, he/she feels like he/she is choking
People tell me that my child worries too much
My child doesn’t like to be away from his/her family
My child is afraid of having anxiety (or panic) attacks
My child worries that something bad might happen to his/her parents
My child feels shy with people he/she doesn’t know well
My child worries about what is going to happen in the future
When my child gets frightened, he/she feels like throwing up
My child worries about how well he/she does things
My child is scared to go to school
My child worries about things that have already happened
When my child gets frightened, he/she feels dizzy
My child feels nervous when he/she is with other children or adults and he/she has to do something while they watch him/her (for example: read aloud, speak, play a game, play a sport)
My child feels nervous when he/she is going to parties, dances, or any place where there will be people that he/she doesn’t know well
My child is shy

Counseling Intake Form

Advanced Therapy Clinic Counseling

Child/Adolescent BioPsychoSocial Assessment

Family Dynamics

Risk Assessment

History of Substance Use/Abuse

Medical Information

Trauma History

School History

Additional Supports

Strengths

CYW Adverse Childhood Experiences Questionnaire (ACE-Q) Child

Screen for Child Anxiety Related Disorders (SCARED)